Have You Had Your Colonoscopy Yet? –A Ludicrous Colonoscopy Rule and the ACA


“An ounce of prevention” we all know is good medicine. An
example is colonoscopy. It was time for mine so after some lengthy
procrastination I called and set up an appointment which I soon found a
perfectly good reason to postpone for a few weeks. A common occurrence. The
government wants me (and you) to not procrastinate, at least not because of the
cost. The Affordable Care Act (ACA or Obamacare) makes an effort to get more
people to get preventive care screening by requiring that there be no
deductibles or co-pays for defined screening and prevention services. Sounds
good. But,  in this Part 8 of my Medicare
series, there may be a catch, as I soon learned.

The concept and purpose of colonoscopy is to find a polyp and
remove it before it turns into cancer. Colon cancers arise from polyps. Polyps
are common but only a minority of polyps progress to cancer. But if removed
they obviously cannot become colon cancer. Colon cancer is the third most
common cancer in men and women in the USA with about 150,000 new cases per year,
behind only lung, breast and prostate cancers. And it causes about 50,000
deaths per year. Prevention obviously makes sense.

On my appointed day I arrived at 8:25am having had clear
liquids for 24 hours and the effects of a very strong purgative. I was pleased
that part was now over. The receptionist seemed like she already had a long day
but was nevertheless efficient. By 8:35 I was in a cubicle getting into my
procedure gown. Thelma – a wonderful nurse and nurse administrator who had come
out of retirement for the intellectual stimulation of working with people –
reviewed my pre-completed history and kept up a patter while another nurse
deftly inserted an IV. The senior anesthesiologist came by and then the
gastroenterologist, Dr Kester Crosse. I was whisked off to the procedure room,
slipped off to sleep and awoke back in the cubicle. Dr Crosse came by to say
that the procedure went smoothly, that he found a polyp which looked benign and
that he had removed it. The pathology report would be back in few days. Another
cheery nurse chatted with me and my wife for about fifteen minutes; her medical
purpose was to be sure I did not aspirate before fully regaining alertness.
When she was satisfied that I was really awake and alert she let me get up and
get dressed. We walked out at 9:32am. Most everyone at Digestive Diseases
Associates had been friendly, all had been competent and all had done their job
effectively. Very efficient and satisfying to me.

The Medicare and Medigap statement came in a few weeks. Dr
Crosse had billed $964. Medicare reduced this to $327.61 as per its formula. In
other words, Medicare says a colonoscopy is worth about $328 and it paid its
portion of that amount or $262. The doctor is not allowed to “balance bill” me
for the rest of what he had originally charged. In order to participate with
Medicare he, by contract, has to accept the price Medicare determines. Since
Medicare generally pays about 75% of covered services, the bill next went to my
Medigap provider (Carefirst Blue Cross/BlueShield in my case.) They did not pay
the remainder stating correctly that I have a high deductible policy. So the
doctor’s office sent me a bill for the $65.57. I paid it. But what about the
new Medicare rule in the ACA/Obamacare that there are to be no co-pays or
deductibles for such preventive services?

A check of the www.healthfinder.gov
 web site stated that colonoscopy was
covered by the ACA and that   “If your
doctor finds polyps inside your colon during testing, these growths can be
removed before they become cancer.”

I decided to call the doctor’s billing office to check.
After the clerk talked to her supervisor she called back to say that I was correct
that there was to be no deductible if it was a simple “screening” colonoscopy.
But since the doctor had found and removed a polyp it became a therapeutic
procedure. Medicare and Medigap (and apparently commercial insurers as well for
those under 65) do not recognize this as a preventive screening procedure under
the ACA guidelines. Hence I was on the hook for the remaining $65.52. By chance
I was at a breakfast shortly after with a senior person at Blue Cross who
confirmed that, yes, this was the rule. I also received a facility charge
(nurses, procedure room, equipment, cleaning, etc.) of $695; Medicare reduced
that to $391. This left a Medigap portion of $78.15 but again it was my
responsibility to pay. Finally were the anesthesiologist s’ bills totaling $975.
Medicare reduced that to $150, paid $65 leaving me with a bill of $66. So altogether
it cost me just under $250 to have the colonoscopy and the peace of mind that
all is in order. Not a bad value.

Admittedly $250 was not a huge amount of money but it
strikes me as strange, to say the least, for Medicare rules to say that, since
Dr Crosse removed a polyp while doing the colonoscopy, then it was no longer a
preventive/screening procedure.

As an aside, I happen to be a big believer in high
deductibles. I think that Medicare should be totally changed so that everyone
(except the financially challenged) should be required to have a high
deductible. That would engage patients into more dialogue with their physicians
and lead to better quality at lower cost. I have posted and written an
op-ed in the Washington Times about this
concept.

But that is not what Congress set into law in the ACA, i.e.,
Medicare recipients would not pay deductibles for specified preventive screening,
including colonoscopy. The whole point and purpose of the colonoscopy is to
look for polyps and to remove them if found. It makes little common sense to claim
that polyp removal changes the procedure from screening to therapy and
therefore not eligible for the no deductible rule. Admittedly, my argument can
be challenged. For example, a screening test for cholesterol would have no
deductible but the drug treatment for high cholesterol would of course be
another matter. Similarly, if a mammography detects probable breast cancer, the
subsequent treatment would not be covered with no deductible. But in the
colonoscopy example, the procedure is underway, the doctor finds a polyp and,
as part of the process, removes it. Maybe there should be a separate bill just
for the polyp removal part and a deductible for that portion. The facility
charge would be the same except for sending the specimen off to pathology and I
doubt the anesthesia was any longer or more complicated as a result of the
polyp removal.  So most of the
deductibles would be eliminated as per Congressional intent.

I wonder what our elected representatives really intended –
or maybe they never really thought about the details.