Some Quotes and Links about Colonoscopy Co-Pays

Last March, I had a routine screening colonoscopy at a major medical center, Cedars-Sinai (Los Angeles).  After six months of silence, I suddenly got a bill from Cedars for $4000 because my insurer (California Blue Shield) had denied the claim.   This is ridiculous - it was a completely routine, legally covered, no-copay (no-deductible) service.   I have no idea what happened to my transaction that was different than the thousands of bills that Cedars must submit to a range of insurers (and often California Blue Shield) for screening colonoscopy.    But I'm not tied up in a mess of 30 minute calls to the provider, 30 minute calls on hold to the insurer, each asking me to call the other, and so on.

I pulled a range of government links that screening services are covered under the Affordable Care Act with neither deductible nor copay.  

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GOVT LINK:

https://www.healthcare.gov/preventive-care-adults/

All Marketplace health plans and many other plans must cover the following list of preventive services without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible.

ASSOCIATION LINK:

https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/screening-coverage-laws.html

The law stipulates that there should be no out-of-pocket costs for patients, such as co-pays or deductibles, for these screening tests. But the definition of a "screening" test can sometimes be confusing, as discussed below.

Kaiser Article

https://www.kff.org/report-section/coverage-of-colonoscopies-under-the-affordable-care-acts-prevention-benefit-report/

From 2012, early on under the ACA, but describes: Confusion/

Long 2012 report.

Examples of patients harassing their insurer to get the correct adjucation.

Govt Link:  Official ACA guidance and regulations

https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs12#Coverage_of_Preventive_Services

PHS Act section 2713 and the interim final regulations[5] require non-grandfathered group health plans and health insurance coverage offered in the individual or group market to provide benefits for and prohibit the imposition of cost-sharing requirements with respect to, the following:  (...)

Q5: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the USPSTF recommendation, is it permissible for a plan or issuer to impose cost-sharing for the cost of a polyp removal during the colonoscopy?

No. Based on clinical practice and comments received from the American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and the Society for Gastroenterology Nurses and Associates, polyp removal is an integral part of a colonoscopy. Accordingly, the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure. On the other hand, a plan or issuer may impose cost-sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.   

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For Medicare patients, there has been a slower pathway to avoiding copays when the colonoscopy includes a biopsy.  However, that is moving to no-copay, no-deductible status based on ongoing updates to law and regulations.  (See discussion near the bottom of my 7/13/2021 blog here.)