The Mystery of Cost Sharing for Colon Cancer Screening

We know that screening for colon cancer saves lives. The US Preventive Services Task Force (USPSTF) final report notes that adherence to screening recommendations could prevent an estimated 20 to 24 deaths for every 1,000 Americans who take this life-saving step. The ability for screening to save lives – as well as money – is why the Affordable Care Act (ACA) requires private insurance to cover these preventives services without a deductible or co-pay.

So if the law requires that insurers not charge a co-pay for all A rated screening tests, why do some patients getting a screening colonoscopy receive a bill? Why do some insurance plans charge a co-pay for the Cologuard DNA stool test and why do some plans refuse to cover CT Colonography even though both are A rated?

There are two different reasons for this mystery. Unfortunately, the Centers for Medicare and Medicaid Services (CMS) could easily solve them but to date has failed to act.

Let’s start with colonoscopies. No private insurance plan can charge you for routine screening; but if your doctor finds and removes a polyp, now it is coded as “diagnostic” and you wake up with a co-pay anywhere from $600 to $1,500 or more. Considering that the whole reason to have a colonoscopy is to remove polyps and prevent colon cancer, we doubt that Congress ever intended to make this payment distinction and that CMS’ interpretation of the ACA is misguided. We believe that CMS has the power to correct this without Congressional action but have refused to do so. Thankfully, Congressmen Payne from New Jersey and Dent from Pennsylvania have introduced House Bill 6275 to inform CMS that Congress never intended to stick you with a bill after the fact. The Colon Cancer Alliance applauds this bi-partisan legislation and strongly urges action on the bill during this lame duck session.

Secondly, CMS looks to the USPSTF to determine which screening methods should be A rated. In their most recent report, both Cologuard and CT Colonography were A rated; so if the law requires that A rated preventive services be provided without co-pay, then patients with private insurance can obtain these without cost – right? Well, maybe or maybe not.  Some plans say as long as they offer one method, they don’t have to offer others, while some plans have asked CMS for guidance. The Colon Cancer Alliance has written to CMS so we can tell our community what the answer is – in one case we got an unrelated answer, in the other no response.

The costs for private insurance and tax-payer bill for Medicare is growing at an unsustainable rate, but here is one area where an additional investment in prevention will save money. Treating one case of late-stage colorectal cancer for one year costs about $120,000. The average screening colonoscopy costs $2,500, so over 10 years is $250. So why would we want to create any financial disincentives for at-risk adults to be screened for colon cancer? 

The USPSTF made two points very clear in their report:

  1. Screening for colorectal cancer saves lives; and
  2. Patients need choices of screening methods if we are to increase the screening rate.

Now the time has come for CMS to help us increase the screening rate by eliminating its self-imposed bureaucratic interpretations of the ACA which creates unnecessary financial disincentives for screening. And, if CMS won’t act, Congress needs to. Let your Congressional Representative know we need to pass HR 6275.

 

And, as always, we encourage you to Speak Up and Speak Out.

1 reply
  1. Dave Bell
    Dave Bell says:

    This is a great article and a definite challenge to screenings when insurance companies do the “bait and switch” of changing the coding from screening to diagnostic work if polyps are found. The Colon Cancer Prevention Project (http://kickingbutt.org) with our lobbyist was instrumental in getting legislation passed at the state level in Kentucky to make sure a colonoscopy or other screening method is covered along with diagnostic work if needed. I know we can do additional work at the federal level which we will advocate for, but there is work to be done at the state level also. Here is an overview of our work: https://coloncancerpreventionproject.org/new-screening-coverage-in-ky-starts-this-month/

    keep up the great work!

    Dave Bell
    CEO
    Colon Cancer Prevention Project

    Reply

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