Under the health care reform law, many preventive screening tests must now be offered with no co-pay or other form of cost sharing. However, a new study by the Kaiser Family Foundation, American Cancer Society, and National Colorectal Cancer Roundtable demonstrates that patients may be billed for screenings under certain circumstances that are not always apparent before the tests occur. The study, which focuses on colonoscopies, indicates that many patients have become confused when asked to pay for a portion of their colonoscopy procedures, and that the “no co-pay” provision is inconsistently applied.¹

Background on the colon cancer screening requirement

The Patient Protection and Affordable Care Act (PPACA) provides that new health insurance plans sold or renewed on or before September 23, 2010, cannot require insured people to share the costs of a number of preventive health care screenings, including colonoscopies that screen for colon cancer. The preventive care provision is aimed at encouraging people to get proactive tests for a variety of ailments that can be treated more effectively and less expensively when discovered early.

In some instances, however, patients have been unexpectedly billed for costs associated with colonoscopies. This has occurred when a) polyps were removed during the colonoscopy, b) the colonoscopy was performed after blood was found in the stool, or c) the colonoscopy was performed because the patient had a significant family history of colon cancer.

What counts as “screening”?

The confusion apparently arises from different interpretations of the term “screening.” When a colonoscopy involves polyp removal — a condition that is usually not known until the test is underway — many insurers determine the test to be a “diagnostic” procedure, rather than a screening. This determination allows patients to be billed for the service without violating the preventive care provision under the PPACA. Likewise, a colonoscopy that follows some other indication of trouble — either another possible cancer symptom or a family history of colon cancer — may no longer be considered a screening test. To further complicate the issue, providers and insurance claim processing systems use inconsistent methods for defining which procedures should not be subject to cost sharing.

In the absence of federal guidance on this issue, some insurers have decided to waive cost sharing for all colonoscopy procedures, including polyp removal, no matter the context. According to the study, medical directors feel the simplicity of this approach helps increase patients’ willingness to undergo these valuable screenings, promotes consistency and avoids complaints and confusion. Others are unwilling to change their policies until more guidance becomes available. The Department of Health and Human Services is reported to be considering whether to issue additional guidance about the health care law’s preventive care benefits.

What you need to know now

Until new guidance is issued, cost-sharing prohibitions for some colon cancer screening procedures may continue to be applied inconsistently. This may also be true for other types of preventive screening tests, such as mammograms.

• Impact on employers — Employers may find themselves fielding employee questions and complaints if employees are billed unexpectedly for the cost of some screening procedures, including colonoscopies. They should prepare themselves for such inquiries and review how their insurance provider determines which preventive care benefits are not subject to cost sharing.
  
  
• Impact on employees — To avoid unexpected costs, employees who take advantage of free preventive care should, before their screening appointments, ask insurers for clear information about which exact procedures are covered without cost sharing. They should also find out the circumstances under which a screening test may become a diagnostic procedure that’s not covered by the preventive care provisions in the PPACA.
  
  
• Impact on brokers — As always, brokers need to educate themselves on these requirements to continue to serve as trusted advisors on key employer questions.