Preventive care: It’s free, except when it’s not

CARLA K. JOHNSON

AP Med­ical Writer

CHICAGO — Bill Dun­phy thought his colonoscopy would be free.

His insur­ance com­pany told him it would be cov­ered 100 per­cent, with no copay­ment from him and no charge against his deductible. The nation’s 1-year-old health law requires most insur­ance plans to cover all costs for pre­ven­tive care includ­ing colon can­cer screen­ing. So Dun­phy had the pro­ce­dure in April.

Then the bill arrived: $1,100.

Dun­phy, a 61-year-old Phoenix small busi­ness owner, angrily paid it out of his own pocket because of what some pre­ven­tion advo­cates call a loop­hole. His doc­tor removed two non­cancer­ous polyps dur­ing the colonoscopy. So while Dun­phy was sedated, his pre­ven­tive screen­ing turned into a diag­nos­tic pro­ce­dure. That allowed his insur­ance com­pany to bill him.

Like many Amer­i­cans, Dun­phy has a high-deductible insur­ance plan. He hadn’t spent his deductible yet. So, on top of his $400 monthly pre­mium, he had to pay the bill.

“That’s bait and switch,” Dun­phy said. “If it isn’t fraud, it’s immoral.”

Pres­i­dent Barack Obama’s health over­haul encour­ages pre­ven­tion by requir­ing most insur­ance plans to pay for pre­ven­tive care. On the plus side, more than 22 mil­lion Medicare patients and many more Amer­i­cans with pri­vate insur­ance have received one or more free cov­ered pre­ven­tive ser­vices this year. From can­cer screen­ings to flu shots, many ser­vices no longer cost patients money.

But there are con­fus­ing excep­tions. As Dun­phy found out, colono­scopies can go from free to pricey while the patient is under anesthesia.

Breast can­cer screen­ings can cause con­fu­sion too. In Florida, Tampa Bay-area small busi­ness owner Dawn Thomas, 50, went for a screen­ing mam­mo­gram. But she was told by hos­pi­tal staff that her mam­mo­gram would be a diag­nos­tic test — not pre­ven­tive screen­ing — because a pre­vi­ous mam­mo­gram had found some­thing sus­pi­cious. (It turned out to be nothing.)

Know­ing that would cost her $700, and know­ing her doc­tor had ordered a screen­ing mam­mo­gram, Thomas stood her ground.

“Either I get a screen­ing today or I’m putting my clothes back on and I’m leav­ing,” she remem­bers telling the hos­pi­tal staff. It worked. Her mam­mo­gram was counted as pre­ven­tive and she got it for free.

“A lot of women … are get­ting labeled with that diag­nos­tic code and hav­ing to pay year after year for that,” Thomas said. “It’s a loop­hole so insur­ance com­pa­nies don’t have to pay for it.”

For par­ents with sev­eral chil­dren, costs can pile up with unex­pected copays for kids need­ing shots. Even when copays are inex­pen­sive, they can blem­ish a patient-doctor rela­tion­ship. Robin Brass­ner of Jer­sey City, N.J., expected her doc­tor visit to be free. All she wanted was a flu shot. But the doc­tor charged her a $20 copay.

“He said no one really comes in for just a flu shot. They inevitably men­tion another ail­ment, so he charges,” Brass­ner said. As a new patient, she didn’t want to start the rela­tion­ship by com­plain­ing, but she left feel­ing irri­tated. “Next time, I’ll be a lit­tle more assertive about it,” she said.

How con­fused are doctors?

“Extremely,” said Cheryl Gregg Fahren­holz, an Ohio con­sul­tant who works with physi­cians. It’s com­mon for doc­tors to deal with 200 dif­fer­ent insur­ance plans. And some older plans are exempt.

Should insur­ance now pay for aspirin? Aspirin to pre­vent heart dis­ease and stroke is one of the cov­ered ser­vices for older patients. But it’s unclear whether insur­ers are sup­posed to pay only for doc­tors to tell older patients about aspirin — or whether they’re sup­posed to pay for the aspirin itself, said Dr. Jason Span­gler, chief med­ical offi­cer for the non­par­ti­san Part­ner­ship for Prevention.

Stop-smoking inter­ven­tions are also sup­posed to be free. “But what does that mean?” Span­gler asked. “Does it mean coun­sel­ing? Nico­tine replace­ment ther­apy? What about drugs (that can help smok­ers quit) like Well­butrin or Chan­tix? That hasn’t been clearly laid out.”

But the great­est source of con­fu­sion is colono­scopies, a test for the nation’s sec­ond lead­ing can­cer killer. Doc­tors use a thin, flex­i­ble tube to scan the colon and they can remove pre­can­cer­ous growths called polyps at the same time. The test gets credit for low­er­ing col­orec­tal can­cer rates. It’s one of sev­eral colon can­cer screen­ing meth­ods highly rec­om­mended for adults ages 50 to 75.

But when a doc­tor screens and treats at the same time, the patient could get a sur­prise bill.

“It erodes a trust rela­tion­ship the patients may have had with their doc­tors,” said Dr. Joel Brill of the Amer­i­can Gas­troen­tero­log­i­cal Asso­ci­a­tion. “We get blamed. And it’s not our fault,”

Cindy Holtz­man, an insur­ance agent in Mari­etta, Ga., is telling clients to check with their insur­ance plans before a colonoscopy so they know what to expect.

“You could wake up with a $2,000 bill because they find that lit­tle bitty polyp,” Holtz­man said.

Doc­tors and pre­ven­tion advo­cates are ask­ing Con­gress to revise the law to waive patient costs — includ­ing Medicare copays, which can run up to $230 — for a screen­ing colonoscopy where polyps are removed. The Amer­i­can Gas­troen­tero­log­i­cal Asso­ci­a­tion and the Amer­i­can Can­cer Soci­ety are push­ing Con­gress fix the prob­lem because of the con­fu­sion it’s caus­ing for patients and doctors.

At least one state is tak­ing action. After com­plaints piled up in Ore­gon, insur­ance reg­u­la­tors now are work­ing with doc­tors and insur­ers to make sure patients aren’t get­ting sur­prise charges when polyps are removed.

Florida’s con­sumer ser­vices office also reports com­plaints about colono­scopies and other pre­ven­tive care. Cal­i­for­nia insur­ance bro­ker Bon­nie Milani said she’s lost count of the com­plaints she’s had about bills clients have received for pre­ven­tive services.

“‘Con­fu­sion’ is not the word I’d apply to the med­ical offices pro­duc­ing the bills,” Milani said. “The word that comes to mind for me ain’t nearly so nice.”

When it’s work­ing as intended, the new health law encour­ages more patients to get pre­ven­tive care. Dr. Yul Ejnes, a Rhode Island physi­cian, said he’s per­son­ally told patients with high deductible plans about the ben­e­fit. They weren’t plan­ning to sched­ule a colonoscopy until they heard it would be free, Ejnes said.

If too many patients get sur­prise bills, how­ever, that advan­tage could be lost, said Stephen Finan of the Amer­i­can Can­cer Soci­ety Can­cer Action Net­work. He said it will take fed­eral or state leg­is­la­tion to fix the colonoscopy loophole.

Dun­phy, the Phoenix busi­ness­man, recalled how he felt when he got his colonoscopy bill, like some­thing “under­handed” was going on.

“It’s the intent of the law is to cover this stuff,” Dun­phy said. “It really made me angry.”

Posted by Staff Reports Obits on Dec 28 2011. You can follow any responses to this entry through the RSS Feed. Comments can be made below.