Philip Keith / KHN
Elizabeth Melville and her husband are slowly hiking all 48 mountain peaks at 4,000 feet in New Hampshire.
“I want to do everything I can to stay healthy so I can do skiing and hiking in my 80’s – hopefully even in my 90’s!” Melville, a 59-year-old part-time ski instructor who lives in the holiday town of Sunapi.
So when her primary care doctor advised her to be screened for colorectal cancer in September, Melville prepares for her colonoscopy on duty and visits the outpatient department at New London Hospital, which was considered a zero-cost procedure.
Typically, colonoscopy screening is performed every 10 years, starting at age 45. However, for people with a history of polyps, more frequent screening is often recommended, as polyps may be a precursor to malignancy. A benign polyp of Melville was removed during a colonoscopy about six years ago.
Melville’s second test was the same as his first: with the exception of a small polyp, which the gastroenterologist excluded while he was asleep. It was also majestic. So he thought he had worked for several years with the least favorite treatment obligation of many patients.
Then came Bill.
Patient: Elizabeth Melville, 59, has a signature health plan that her husband receives through his employer. It includes a $ 2,500 separate deductible and 30% currency insurance.
Medical Services: A screening colonoscopy, including the removal of a benign polyp.
Service Provider: A 25-bed facility at New London Hospital, New London, New Hampshire. It is part of the Dartmouth Health System, a non-profit academic medical center and a regional network of five hospitals and more than 24 clinics with annual revenues of approximately 3 billion.
Total bills: Method, স্থ 10,329 for anesthesiologist and gastroenterologist. Signer’s negotiation rate was $ 4,144, and Melville’s shares under his insurance were 2,185.
Last hour: The Affordable Care Act provides free preventive health care for patients, including free mammograms and colonoscopy. But for the purpose of screening, there is a wave playing field for charging once a procedure for diagnosis has been completed. Doctors and hospitals often decide when these departments will be relocated and a patient may be charged – but these decisions are often controversial.
Regular screening for colorectal cancer is one of the most effective tools for prevention. Screening colonoscopies reduces the relative risk of colorectal cancer by 52% and the risk of death by 62%, according to a recent study.
The U.S. Preventive Services Task Force, an interdisciplinary group of medical experts, recommends regular colorectal cancer screening for the average at-risk people between the ages of 45 and 75.
Colonoscopies can be classified for screening or diagnosis. How they are classified makes all the difference for patients to spend out of pocket. The former usually bears no cost to patients under the ACA; The latter can make the bill.
Centers for Medicare and Medicaid services have repeatedly stated over the years that under the ACA’s preventive services provision, screening is considered an integral part of a polyp removal procedure during colonoscopy and should not change patients’ cost-sharing obligations.
After all, that’s the whole point of screening – to see if polyps have cancer, they must be removed and examined by a pathologist.
Many may face this situation. According to the American Society for Gastrointestinal Endoscopy, more than 40% of people over the age of 50 have prenatal polyps in the colon.
Anna Howard, head of policy at the American Cancer Society’s Cancer Action Network, said those with higher-than-average cancer risks may face higher bills and are not protected by law.
Anyone with a family history of colon cancer or a personal history of polyps increases the risk profile and insurers and providers may charge based on that. “From the very beginning, [the colonoscopy] Can be considered diagnostic, “Howard said.
In addition, performing a screening colonoscopy sooner than the proposed 10-year interval, as Melville did, could expose someone to a cost-sharing charge, Howard said.
Coincidentally, Melville’s 61-year-old husband performed a screening colonoscopy at the same facility with the same doctor a week after his procedure. Despite having a previous colonoscopy just five years ago due to her family history of colon cancer and her high risk, her husband was not charged for the test.
The main difference between the two experiences: Melville’s husband’s polyp was not removed.
Resolution: When Melville received notice of the 2,185 debt, he initially thought it was a mistake. After her first colonoscopy she had nothing to borrow. But when he called, a signer’s representative informed him that the hospital had changed the billing code for his procedure, from screening to diagnostics. A call to the Dartmouth Health Billing Department confirmed this explanation: He was told he was billed because a polyp had been removed – the procedure is no longer preventative.
During a subsequent three-way call to Melville with representatives from both the health system and Signna, Dartmouth health workers reiterated that position, Melville said. “[She] It was very firm with this decision that once the polyp was found, the whole procedure changed from screening to diagnostic, ”he said.
Dartmouth Health has refused to discuss Melville’s case with KHN, although it has allowed him to do so.
Following KHN’s investigation, Melville was contacted by Joshua Compton of Conifer Health Solutions on behalf of Dartmouth Health. Compton said diagnostic codes were inadvertently removed from the system and Melville’s claim was being recycled, Melville said.
Philip Keith / KHN
After contacting KHN, Cigna investigated the claim. Justin Sessions, a spokesman for Signer, said in a statement: “This issue was quickly resolved when we learned that the provider had submitted the claim incorrectly.
Takeway: Melville did not expect to be billed for this procedure. It looked like his first colonoscopy, about six years ago, when he was not charged for polyp removal.
But before getting a selective approach, such as cancer screening, Howard says it’s always a good idea to try to figure out any coverage minefields. Remind your provider that the ACA government needs to explain that even if the polyp is removed, colonoscopies will be considered screening.
“Contact the insurer before the colonoscopy and say, ‘Hey, I just want to understand what the coverage limitations are and what the costs might be out of my pocket,'” Howard said. Billing from an anesthesiologist – who prescribes a single dose of sedative – can also be a problem with colonoscopy screening. Ask if the anesthesiologist is in-network.
Be aware that physicians and hospitals must provide a reasonable estimate of patients’ expected costs prior to the planned procedure under the No Surprise Act, which will take effect this year.
Take the time to read any paperwork you need to sign and build your antenna for the problem. And, importantly, ask to see the documents ahead of time.
Melville said a health care billing representative told him that one of the papers he signed at the hospital on the day of his procedure was that if a polyp was discovered, the procedure would become diagnostic.
Melville no longer has the paperwork, but if Dartmouth Health had its signature on such a document, it would probably be a violation of the ACA. However, there is little “direct federal oversight or enforcement” of the law’s preventive service requirements, said Karen Politz, a senior fellow at KFF.
In a statement describing the general practice at New London Hospital, spokesman Timothy Lund said: “Our physicians discuss the possibility of progressing the process from screening colonoscopy to diagnostic colonoscopy as part of the informed consent process. All their questions are answered by the attending physician. “
To patients like Melville, though, that doesn’t seem fair. “I still think that if someone had prepared for a colonoscopy to process these choices, it wouldn’t make sense to ask questions and possibly say ‘no thanks’,” he said.
Stephanie O’Neill contributed to the audio portrait with this story.
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