Insurance coverage for a colonoscopy: Be sure to read the fine print

WCSH6 Morning Report
Two weeks ago on the WCSH6 Morning Report, I talked about the importance of early detection of colorectal cancer and shared some information about insurance coverage for screening tests:

The Affordable Care Act requires that all private health plans cover colorectal cancer screening tests as a preventive service without any out-of-pocket costs to patients, even if polyps are detected and removed.

For people on Medicare, the deductible will be waived for colorectal cancer screening tests even when polyps are detected and removed. If the test results in the biopsy or removal of a growth, it is no longer a “screening” test and patients can be charged co-insurance and/or a co-pay.

The Maine Colorectal Cancer Control Program provides no-cost screening services for residents who do not have health insurance and connects them with the resources they need to prevent, detect, and survive colon cancer. Eligibility guidelines include age, income, insurance status, and health history. If you think you, a family member or friend might be eligible to receive services through this program, call the Colon Screening Hotline at 1-877-320-6800.  

Debbie’s story

That afternoon I got an email from a woman who ended up paying around $2000 for a colonoscopy she thought was a preventive test. Her insurance company said it wasn’t and that she would be responsible for out-of-pocket costs. She thought it was important for people to hear what happened to her so they wouldn’t find out the hard way, like she did.

Woman clutching her belly.

Debbie has ulcerative colitis, an inflammatory bowel disease that affects as many as 700,000 people in the United States. Because ulcerative colitis increases the risk of developing colon cancer, Debbie has to have a colonoscopy every two years. She’s covered by her husband’s health insurance and says that when she first started having colonoscopies, she never saw a bill.

That changed in 2010 when her husband got a new job and new health insurance. Debbie turned 50 that year — it’s recommended that people get their first colonoscopy at age 50 and Debbie assumed hers would be considered preventive. “I had called the insurance company,” she explains, “and was told I was fine for my preventive colonoscopy. I never thought ulcerative colitis would be an issue. I ended up paying $1500 toward the deductible and then 30% of the bill up to a certain amount. I didn’t try to appeal because I was so upset and so angry that it caused a flare-up of my colitis. I was like, ‘I cannot deal with this!’”

Preventive vs. diagnostic colonoscopy

I asked Linda Riddell, a fellow Bangor Daily News blogger who covers health insurance issues about Debbie’s predicament. She wrote this response on her Health Unsurance Blog:

“You are bringing out a fine-print detail about the difference between preventive and diagnostic tests. Under the Affordable Care Act, health insurance has to cover preventive tests – including the colonoscopy for people age 50 to age 75 – without charging a co-pay. A test is “preventive” if the patient has no symptoms of disease. The very same test can be “diagnostic” if the patient has symptoms, or in your case, risk of disease. 

Insurers are not required to cover preventive (or “screening”) colonoscopies more frequently than the United States Preventive Task Force recommends. Their guidelines suggest every 10 years for colonoscopies. So, while ulcerative colitis patients may need colonoscopies more frequently, the insurer does not have to cover it with no co-pay.

You can press the issue with the insurer, by appealing when they deny the claim or charge you the co-pay. Another thing that Health Reform requires is a three-level appeal process, with independent people reviewing your claim and your argument.  See HHS’s step-by-step process for appeals. It’s possible that the review process could lead to better coverage of your tests.”

Four years later

Debbie hasn’t had another colonoscopy since 2010. She says she simply couldn’t afford one. Her deductible is now $2500, but she’s afraid to put off the test any longer, so is scheduled to have one in June. Getting Linda’s information/link about how to go through the appeals process was helpful, because that’s exactly what she plans to do this time.

“If I don’t have another flare-up,” she says, “I’ll probably try to put it through the appeals process and see what happens. I will try to do that if I can keep my wits about me. It’s just such a process. Why is the person with a healthy intestine allowed to have this procedure with no cost to them, but the minute you’re diagnosed with something, it’s a whole different ballgame? We’re the ones they should be allowing. It just doesn’t make sense.”

Debbie says she’ll let us know what happens — with her colonoscopy and with her appeal.

 

Diane Atwood

About Diane Atwood

For more than 20 years, Diane Atwood was the health reporter on News Center 6. She's now a regular guest on the Morning Report. Before she became a health reporter, Diane was a radiation therapist/dosimetrist at Maine Medical Center. In 2000, she left the world of reporting to manage marketing and public relations for Mercy Hospital. In 2011, she decided to pursue a longtime dream of being a freelance writer and launched her award-winning blog Catching Health with Diane Atwood.