Screening colonoscopies are included in the preventive care benefits mandated by the ACA and they're supposed to be covered without any patient cost-sharing, but are they really free?
You turn 50 and before the candles on your cake have stopped smoking your loved ones start talking to you about getting a colonoscopy. My husband, Patrick, finally gave in and scheduled his last month. I read that one of the reasons people don't get a screening colonoscopy when they turn 50 is the hassle of dealing with the insurance coverage, so I figured I'd write about his experience. I didn't expect it to cost us anything because screening colonoscopies are included in the preventive care benefits mandated by the ACA and they're supposed to be covered without any patient cost-sharing. I was surprised when that wasn't quite how it played out. Here's a breakdown of the bills. (We have ASHA's high-deductible plan, Choice Plus with HSA.)
When the ACA first required health plans to cover preventive services, consumers encountered problems when a polyp was discovered during the procedure. The doctor would, of course, remove the polyp, but even if it was benign, they would no longer bill the procedure as preventive. The government came out with a clarification that included treatment being done at the same time or "integral to the procedure" and specifically cited removal of a polyp, so this shouldn't be an issue for you. Just confirm that the provider will be billing the procedure with a preventive care code.
Unfortunately, that's as far as the government's clarification went and I've run into a surprising interpretation from UHC. They are saying the initial consultation with the gastroenterologist and the prep kit are NOT integral to the procedure. Therefore, the services are subject to the deductible or the copays dictated by your plan. (Baffling, I know. I'll continue to look into it.)
Another common problem is winding up with a anesthesiologist that is out-of-network. This happened to Patrick, but the claims were reprocessed with one phone call to UHC. After that was done, I called the anesthesiologists office and, without my even making the request, they told me they'd written off the balance. In some instances, you may have to write a letter of appeal. ASHA staff can contact Health Advocate and they will write the appeal for you.
All in all, the screening cost us $209 and the money ASHA contributed to our HSA ($2,000) more than covered it. I compared notes with a colleague that has our Choice Plus PPO. She paid a $15 copay for the office visit and $25 for the prep kit for a grand total of $40.
I'm a bit of a skeptic when it comes to some screenings, but it is widely believed that preventive colonoscopies detect and prevent colorectal cancer. Colorectal cancer is the second leading cause of cancer death in the U.S. and the third most common cancer in men and women. Gastroenterologists actually remove precancerous polyps and small cancers during a screening colonoscopy. The number of deaths from colon cancer could be reduced if more people were screened. Listen to your loved ones and set aside the money whether it's $40 or $200 to take care of yourself.
- Colon cancer screening tests: Important but not necessarily fully covered ~Washington Post
- Colonoscopy: When you need it—and when you don’t
- U.S. Preventive Services Task RecommendationsForce
- Get Tested for Colorectal Cancer
- UHC Preventive Care Services
- Coverage of Colonoscopies Under the Affordable Care Act’s Prevention Benefit – Report – 8351 ~Kaiser Family Foundation
- How To Avoid A Colonoscopy Billing Kerfuffle ~NPR
- Top 3 Errors Made by Consumers When Receiving a Screening Colonoscopy
- Colorectal cancer screening tests ~American Cancer Society (includes alternative tests)