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The Insurance Question on Colon Cancer Screening

Posted on Apr 18, 2013 by Ailee Slater ()  | Tags: Affordable Care Act, colon cancer, colon polyps, colonoscopy, colorectal cancers, obamacare, preventive services

This week, an article published by Kaiser Health News called attention to the issue of colon cancer. Excluding lung cancer, colorectal cancers are responsible for the most cancer-related deaths in the United States; however, the recent media interest in colon cancer has nothing to do with fatality rates - it has to do with health insurance.

According to Kaiser, some patients and doctors are becoming unsure about which aspects of colon cancer screening fall under the title of "preventive services," and therefore must be covered cost-free by insurers. Thanks to Obamacare, all non-grandfathered insurance plans must offer patients a range of preventive services, with any cost-sharing from insured consumers.

Examples of preventive services that must be covered by an insurance plan include cholesterol screening, diet counseling, and immunizations for hepatitis and the flu. Screening for colon cancer is another service that insurers are expected to provide; however, there is uncertainty about the extent to which a colonoscopy represents a purely preventive service.

For example, if a polyp (a small growth on the surface of the large intestine) is discovered during a colonoscopy, is the removal of that polyp defined as preventive care? If yes, than an insurance company is required by law to pay for the procedure. However, some insurers have argued that polyp removal is a therapeutic procedure rather than a preventative one, and so patients should be billed for the cost of treatment.

This uncertainty about the coverage of colonoscopy services was brought to attention thanks to a report last year headed by researchers from Georgetown University. Through conducting interviews with stakeholders and regulatory officials in the insurance industry, it was found that insurers vary greatly in their definitions of which colon screening procedures are preventive services.

The insurance providers interviewed in this Georgetown study reported that patients, too, were unclear about which procedures were covered by insurance. Interview subjects admitted to having received complaints from patients who had undergone colon procedures, and were then asked to help cover part of the cost of care; a cost which the patients had assumed would be fully covered by their insurer.

Besides the issue of polyp removal during a colon screening, confusion may arise when a doctor recommends a colonoscopy as part of a follow up procedure to a positive stool blood test. In this case, some insurers say that the colonoscopy is not a preventive screening, but rather part of a larger procedure to treat a stomach or intestine problem. Likewise, individuals at higher risk for colon cancer may seek screenings more often than the recommended one screening every ten years, and some of these at-risk patients have been unexpectedly billed by their insurers for the cost of the colonoscopy, which the patients had assumed would be fully covered.

In its concluding recommendations, the Georgetown Report advises that the federal government create a more clear guide for insurers and patients to use when determining whether or not a colon procedure counts as a preventive service. Authors of the study finish their report by calling attention to the fact that if clarity in the area of colonoscopies and cost-sharing is not enhanced, the Affordable Care Act's improvements in preventive care services will not be as easily achieved.

Indeed, Kaiser has reported on the case of one man, at high risk for colon cancer, who has decided to forgo colon cancer screening in light of the recent uncertainty as to insurance payment procedure. The patient, a man called Allan Worob, was told that if a polyp were discovered during a colonoscopy, he would be charged the full cost of the procedure - over $2,000 U.S. dollars. Although his insurance company later rescinded that initial statement and informed Worob that the colonoscopy would be fully covered regardless of whether or not polyps were found, Worob still decided that having the test was too much of a financial risk.

The Affordable Care Act emphasizes the importance of preventive procedures and screenings because solving medical maladies in their earlier stages means fewer costs, and better results, later on. Regular screening tests are one of the best ways to prevent colorectal cancer, so it's no surprise that when Obamacare was passed, colonoscopies and cancer screening were included in the list of preventive procedures to be utilized cost-free by an insurance consumer.

According to the American Cancer Society, rates of colorectal cancer in the United States have been steadily decreasing during the past two decades, thanks in large part to widespread cancer screening. If the current confusion over the insurance costs and coverage of colon cancer screenings persists, we could see a situation in which the benefits of preventive colon care become less accessible. Hopefully, with more consistent regulations and better insurance coverage clarity up front, such a circumstance will not occur.

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