The ACA Law and Screening versus Diagnostic Testing

Screening versus diagnosis. It is important that you know the difference and ask the right questions before signing up for the procedure. A simple change in wording from the doctor could change the patient's responsibility for the bill from zero to a significant unexpected medical bill.


The Affordable Care Act made preventive health care such as #mammograms and #colonoscopies free of charge to #patients without cost sharing. But there is wiggle room about when a procedure was done for screening purposes, versus for a diagnosis. And often the doctors and hospitals are the ones who decide when those categories shift and a patient can be charged — but those decisions often are debatable.


Source: https://khn.org/news/article/surprise-medical-bill-colonoscopy-screening-versus-diagnosis/

Typically, screening colonoscopies are scheduled every 10 years, starting at age 45. But more frequent screenings are often recommended for people with a history of polyps since 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 her first one: routine, except for one small polyp that the #gastroenterologist snipped out while she was sedated. It too was #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, who is covered under a #Cigna health plan that her husband gets through his employer. It has a $2,500 individual deductible and 30% #coinsurance.


Medical Service: A screening #colonoscopy, including removal of a benign #polyp.


Total Bill: $10,329 for the procedure, anesthesiologist, and gastroenterologist. Cigna’s negotiated rate was $4,144, and Melville’s share under her insurance was $2,185.


What changed? Why was the first colonoscopy free and the second costing her $2,185.00?


One word on the bill screening vs. diagnosis.


Colonoscopies can be classified as #screening or for #diagnosis. How they are classified makes all the difference for patients’ out-of-pocket costs. The former generally incurs no cost to patients under the #ACA; the latter can generate bills.


The Centers for #Medicare & #Medicaid Services has clarified repeatedly over the years that under the preventive services provisions of the ACA, removal of a polyp during a screening colonoscopy is considered an integral part of the procedure and should not change patients’ cost-sharing obligations.


After all, that’s the whole point of screening — to figure out whether polyps contain #cancer, they must be removed and examined by a #pathologist.


Here is the catch, if you have a family history of cancer that places you at higher risk and increased frequency to be tested the doctor and/or facility can say the procedure is "diagnostic" from the start and therefore subject to full billing and NOT free per the ACA screening umbrella.


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.


So what's the answer? Stay on top of it and ask your provider and confirm that the test is screening.


So what happened with the bill?

Resolution: When Melville received notices about owing $2,185, she initially thought it must be a mistake. She hadn’t owed anything after her first colonoscopy. But when she called, a Cigna representative told her the hospital had changed the billing code for her procedure from screening to diagnostic. A call to the Dartmouth Health billing department confirmed that explanation: She was told she was billed because she’d had a polyp removed — making the procedure no longer preventive.


During a subsequent three-way call that Melville had with representatives from both the health system and Cigna, the Dartmouth Health staffer reiterated that position, Melville said. “[She] was very firm with the decision that once a polyp is found, the whole procedure changes from screening to diagnostic,” she said.


The good news after a lot of pressure and a news inquiry the facility changed the coding of Melville's colonoscopy and her bill got zero balanced.


Many people don't understand their medical billing and will usually pay it because they don't want their credit to be negatively affected. I say read the fine print. Check with your provider on screenings and their interpretation on the #ACA laws.


"Before getting an elective procedure like a cancer screening, it’s always a good idea to try to suss out any coverage minefields, Howard said. Remind your provider that the government’s interpretation of the ACA requires that colonoscopies be regarded as a screening even if a polyp is removed."

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