Elizabeth Melville and her husband gradually hike the 48 mountain peaks that rise to 4,000 feet in New Hampshire.
“I want to do everything I can to stay healthy so I can ski and hike well into my 80s, maybe 90s!” said Melville, a 59-year-old part-time ski instructor who lives in the resort town of Sunapee.
So when her GP suggested she get screened for colorectal cancer in September, Melville dutifully prepared for her colonoscopy and went to the outpatient department at New London Hospital for what was supposed to be a no-cost procedure. .
As a general rule, screening colonoscopies are scheduled every 10 years from the age of 45. But more frequent screenings are often recommended for people with a history of polyps, as polyps can be a precursor to malignancy. Melville had had a benign polyp removed during a colonoscopy nearly six years earlier.
Melville’s second test was similar to the first: normal, except for a small polyp that the gastroenterologist removed while she was sedated. It was also benign. So she thought she was done with many patients’ least favorite medical obligation for several years.
Then the bill came.
The patient: Elizabeth Melville, 59, is covered by a Cigna health plan that her husband obtains through his employer. It has an individual deductible of $2,500 and coinsurance of 30%.
Medical service: A screening colonoscopy, including the removal of a benign polyp.
Service provider: New London Hospital, a 25-bed facility in New London, New Hampshire. It is part of Dartmouth Health System, a nonprofit academic medical center and regional network of five hospitals and more than 24 clinics with nearly $3 billion in annual revenue.
Total bill: $10,329 for the procedure, the anesthesiologist and the gastroenterologist. Cigna’s negotiated rate was $4,144 and Melville’s share under his insurance was $2,185.
Which give: The Affordable Care Act made preventative health care such as mammograms and colonoscopies free for patients with no cost sharing. But there is wiggle room to charge when a procedure is done for diagnostic rather than screening purposes. Doctors and hospitals often decide when these categories change and a patient can be charged, but these decisions are often debatable.
Getting screened regularly for colorectal cancer is one of the most effective tools people have to prevent it. Screening colonoscopies reduce the relative risk of contracting colorectal cancer by 52% and the risk of dying from it by 62%, according to a recent analysis of published studies.
The US Task Force on Preventive Services, a nonpartisan group of medical experts, recommends regular colorectal cancer screening for people at average risk between the ages of 45 and 75.
Colonoscopies can be categorized as for screening or for diagnosis. How they are categorized makes all the difference to patients’ out-of-pocket expenses. The former generally incurs no cost to patients under the ACA; the latter can generate invoices.
The Centers for Medicare & Medicaid Services have repeatedly clarified over the years that under the ACA’s preventive services provisions, the removal of a polyp during a screening colonoscopy is considered part of the integral to the procedure and should not alter the cost-sharing obligations of patients.
After all, that’s the whole point of screening – to determine if polyps contain cancer, they need to be removed and examined by a pathologist.
Many people may face this situation. More than 40% of people over 50 have precancerous polyps in the colon, according to the American Society for Gastrointestinal Endoscopy.
Someone with a higher than average cancer risk may face higher bills and not be protected by law, said Anna Howard, policy manager at the American Cancer Society’s Cancer Action Network.
Having a family history of colon cancer or a personal history of polyps increases a person’s risk profile, and insurers and providers could charge fees based on this. “From the beginning, [the colonoscopy] could be considered diagnostic,” Howard said.
Additionally, getting a screening colonoscopy earlier than the recommended 10-year interval, as Melville did, could open someone up to cost-sharing fees, Howard said.
Coincidentally, Melville’s 61-year-old husband underwent a screening colonoscopy at the same facility with the same doctor a week after his procedure. Despite her family history of colon cancer and a previous colonoscopy just five years earlier due to its high risk, her husband did not charge anything for the test.
The main difference between the two experiences: Melville’s husband didn’t have a polyp removed.
Resolution: When Melville received notices that she owed $2,185, she initially thought it was a mistake. She hadn’t owed anything after her first colonoscopy. But when she called, a Cigna rep told her the hospital had changed the billing code for her procedure from screening to diagnostic. A call to Dartmouth Health’s billing department confirmed this explanation: she was told she was billed because she had a polyp removed, making the procedure more preventative.
On a subsequent three-way call Melville had with representatives from the health system and Cigna, the Dartmouth Health staff member reiterated that position, Melville said. “[She] was very firm with the decision that once a polyp is found, the whole procedure moves from screening to diagnosis,” she said.
Dartmouth Health declined to discuss Melville’s case with KHN even though it gave him permission to do so.
After KHN’s investigation, Melville was contacted by Joshua Compton of Conifer Health Solutions on behalf of Dartmouth Health. Compton said the diagnostic trouble codes were inadvertently deleted from the system and Melville’s claim is being reprocessed, Melville said.
Cigna also investigated the allegation after being contacted by KHN. Justine Sessions, a spokesperson for Cigna, said: “This issue was quickly resolved as soon as we became aware that the vendor had submitted the claim incorrectly. We have reprocessed the claim and Ms. Melville will not be responsible. disbursements.”
The takeaway: Melville did not expect to be charged for this procedure. It looked exactly like her first colonoscopy, nearly six years earlier, when she hadn’t been billed for the removal of a polyp.
But before undergoing an elective procedure like a cancer screening, it’s always a good idea to try to identify coverage minefields, Howard said. Remind your provider that the government’s interpretation of the ACA requires colonoscopies to be considered screening even if a polyp is removed.
“Contact the insurer before the colonoscopy and say, ‘Hey, I just want to understand what the coverage limits are and what my out-of-pocket expenses might be,’” Howard said. Billing for an anesthesiologist – who simply delivers a dose of sedative – can also become an issue when screening for colonoscopies. Ask if the anesthetist is in network.
Know that doctors and hospitals are required to give good faith estimates of expected patient costs ahead of scheduled procedures under the No Surprises Act, which took effect this year.
Take the time to read all the documents you need to sign and prepare your antennas for problems. And, above all, ask to see the documents in advance.
Melville said a health system billing representative told her that among the paperwork she signed at the hospital the day of her procedure was one saying that if a polyp was found, the intervention would become diagnostic.
Melville no longer has the paperwork, but if Dartmouth Health made him sign such a document, it would likely be in violation of the ACA. However, “there is very little, if any, direct federal oversight or enforcement” of the law’s requirements for preventive services, said KFF senior researcher Karen Pollitz.
In a statement outlining general practices at New London Hospital, spokesperson Timothy Lund said: “Our doctors are discussing the possibility of the procedure changing from a screening colonoscopy to a diagnostic colonoscopy as part of the informed consent process. Patients sign the consent document after hearing these details, understanding the risks, and having any questions answered by the physician providing the care.”
For patients like Melville, however, that doesn’t seem quite fair. She said: ‘I still think asking anyone who has just been prepared for a colonoscopy to process these choices, ask questions and potentially say ‘no thanks’ to any of this is unreasonable.
Stephanie O’Neill contributed to the audio portrait with this story.
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