Health insurance companies discourage colon cancer screening

Colon cancer is the fourth most common form of cancer in the United States. You'd think that insurance companies would want to do their utmost to prevent it. But I've learned that almost all of them don't -- including my insurer, Regence BlueCross BlueShield of Oregon.

On February 18 I had a colonoscopy.

I didn't have any symptoms of colon cancer, but my Gastroenterologist recommended that I get another one, because (1) two years ago my first regular colonoscopy revealed a benign polyp (which was removed), and (2) an imperfect colonoscopy prep obscured part of my colon, so the doctor couldn't see whether any polyps were in that area.

The procedure went fine. It was even enjoyable, in a drugged-up sense. A flat polyp was found and removed in the first colonoscopy's "bad prep" area. Once again, it turned out to be benign.

This is the good news. The bad news arrived in the mail a few days ago: an "Explanation of Benefits" form from Regence of Oregon regarding my colonoscopy. Total Regence Paid was shown in bold at the top.

The amount: $0.00

Total Member Responsibility to Provider(s) was right next to it. The amount: $805.69

I thought, "What the hell?" I was pretty sure that two years ago Regence had paid for most of my first colonoscopy, since this is a preventive screening procedure. I also knew that the Affordable Care Act (a.k.a. "Obamacare") required insurance companies to fully cover preventive care.

Indeed, a summary of Regence of Oregon's new Evolve Plus policy, which I was switched to in July 2010, states:

Preventive care: Preventive services and immunizations are covered according to guidelines set forth by the United States Preventive Services Task Force (USPSTF), Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA).

Some Googling led me to the USPSTF guidelines for colorectal screening, which were referenced by the CDC and seemed to also be the main basis for HRSA policies. Yes, indeed, colonoscopies are a good thing. I read:

Screening for colorectal cancer reduces mortality through detection and treatment of early-stage cancer and detection and removal of adenomatous polyps. The degree to which each of these mechanisms contributes to a reduction in mortality is unknown, although it is likely that the largest reduction in colorectal cancer mortality during the 10 years after initial screening comes from the detection and removal of early-stage cancer. Colonoscopy is a necessary step in any screening program that reduces mortality from colorectal cancer.

So polyp removal is an integral and important part of screening for colon cancer via a colonoscopy. After the doctor spots a polyp during the exam, he or she can remove it through the colonoscope. Screening and prevention go hand in hand, since today's benign polyp can turn into tomorrow's early stage colon cancer.

Why, then, wasn't Regence paying for my colonoscopy, since this is a preventive service under the Affordable Care Act? The government web site that lists covered services says:

If you have a new health insurance plan or insurance policy beginning on or after September 23, 2010, the following preventive services must be covered without your having to pay a copayment or co-insurance or meet your deductible.

Well, my new Evolve Plus policy kicked in on July 1, 2010, so this could explain why the Affordable Care Act doesn't yet control what Regence has to pay for a colonoscopy. But  Regence of Oregon itself says that colonoscopies are fully paid for, as this Regence Evolve Plus flyer says.
Download Regence- Evolve Plus 2011

Preventive care – covered at 100% (no annual benefit maximum) Includes the following when billed as preventive: Routine physical exam, well child care, adult and child immunizations, routine laboratory, radiology and diagnostic procedures including mammography, pap smear, PSA and colonoscopy. (See contract for complete list of preventive care benefits)

Perplexed, I phoned Gastroenterology Specialists of Oregon and talked with their insurance company billing person. She told me that because a polyp was removed, Regence considered the entire colonoscopy a "medical procedure," not a preventive screening.

"That doesn't make any sense," I told her.

Explaining, I said: "At the time I was given a sedative and became unconscious, I had no colon cancer symptoms and was getting a colonoscopy as a screening tool. When I woke up, I still had no symptoms but a benign polyp had been removed. How is it that the colonoscopy changed from being a 100% covered preventive service to a 0% covered medical procedure just because a polyp was removed in the name of prevention?"

(Like many people, I have a high deductible -- $2,500 -- because otherwise my premium would be unaffordable. Since I hadn't met the deductible, Regence didn't pay anything for my colonoscopy. Preventive care isn't subject to the deductible, though.)

"Insurance companies are just trying to save money," she told me. Bastards, I thought.

Colonoscopies aren't a lot of fun. Most people dread getting them. But they're the best way to screen for colon cancer before it spreads, and to excise potentially pre-cancerous polyps.

Yet the billing person told me that every private insurance company she deals with considers that removing a polyp stops a colonoscopy from being a covered preventive service, even though the patient (like me) has no symptoms of colon cancer and the polyp removal is purely preventive, not curative.

Like I said, bastards.

When someone is urged by his or her doctor to get a colonoscopy, the insurance companies don't tell policy-holders that if a polyp is found, you're going to end up getting zero benefits for a preventive service that is described as being covered 100%. That sure sounds like "bait and switch" advertising to me.

Plus, its despicable for insurance companies to act in a way that discourages people from getting colonoscopies. This is a screening tool that is demonstrably effective in preventing colon cancer.

Yet insurers are, in effect, saying to policy holders: "If the doctor doing the colonoscopy removes a pre-cancerous polyp in the course of the procedure, we won't pay for it."

So if somebody is strapped for money, as so many people are these days, he or she could well put off getting a colonoscopy, since there's no way of knowing ahead of time if the insurance company is going to pay 100% or 0% for the expensive procedure.

This is the point made by the American Society for Gastrointestinal Endoscopy (ASGE) and the Colorectal Cancer Coalition.

“Colorectal cancer is a largely preventable disease. Screening for colorectal cancer by colonoscopy identifies polyps and allows them to be removed before they turn into cancer, and that is the basis for colonoscopy as both a screening and colorectal cancer prevention tool,” said M. Brian Fennerty, MD, FASGE, president, American Society for Gastrointestinal Endoscopy.

“We call upon health plans and insurers to fully eliminate the cost burden of colonoscopy colorectal cancer screening by waiving cost- sharing for the screening portion of colonoscopies in the event that they turn therapeutic and a polyp is removed.”

The greatest benefit of colonoscopy is removing polyps that are discovered during screening and by so doing, significantly decreasing the risk for later cancer development.

Converting a screening procedure that is fully covered by insurance with no cost-sharing, to one that does require cost-sharing by the patient after a polyp is found, is both a barrier to screening and inconsistent with the goal of the preventive services provision. The patient who has a polyp removed is the one who benefits the most from the exam and imposing a financial “penalty” could deter the patient from getting screened.

Right on.

But Regence BlueCross BlueShield of Oregon is even worse than this. I told the clinic's billing person that I wouldn't mind paying whatever extra a "polyp-removal colonoscopy" costs versus a "non-polyp-removal colonoscopy." It couldn't be much, since snipping off a polyp is a small addition to the whole colonoscopy experience.

So if Regence said I'd have to do some cost-sharing -- 10% or whatever -- because a polyp was removed during the screening procedure, that'd be fine with me. To refuse to pay anything for a preventive colonoscopy, that's unacceptable.

I'll be complaining to Regence, elected officials, Governor Kitzhaber (a physician), the state Insurance Commission, and anyone else I can think of who could help change this stupid insurance company policy. I don't begrudge insurers an honest return, but gouging policy-holders and risking lives in the name of Almighty Profit is outrageous.

Comments

[Veeper]

If I didn't know you, I'd suspect this is a draft script for a Saturday Night Live skit.

[Rain]

That is disgusting. It seems you have had a lot of trouble with them. Is any other insurance feasible in your area? I will have to look into how ours handles it although we now have Medicare with an add-on; so who knows what it would do about it. They do all seem out to get us!

[Blogger Brian]

Rain, pre-existing conditions are the big problem with switching insurers. We wouldn't be accepted by another insurer at a reasonable cost, and with coverage for our (minor) health problems. So we're stuck with Regence.

When the Affordable Care Act is fully implemented (2014, I believe) the pre-existing condition issue will be eliminated, since everybody in the country will be required to have insurance. But until then, it remains a barrier to switching to a different company.

[Tammy]

We're dealing with this RIGHT now! I was told just the routine colonoscopy is considered surgery and will cost us $4,800 - $5,000!! That is absolutely asinine (and YES, I did mean the pun). I'm shopping around and trying to find a clinic that doesn't consider it surgery.

[Blogger Brian]

Tammy, I'm in the process of appealing my insurance company's determination. I've found some great info/links about this issue that supports our cases. If you're interested in looking at what I've found, email me (address in right sidebar under "email me").

[will Bronstijn]

wow, I feel very sorry for you guys. as mentioned in my other post, I just had a colonoscopy done, and also had one last year.
my cost?? $0. Why?? Because, dear folks, I live in Canada, and we have universal health care. It is so sad that your country is in the grip of insurance companies, and that your
Republicans are in bed with them. Our health care system is not "socialist", whatever that means, and is not broken. Our doctors are paid by the govt., not by the insurers. Our
hospitals are run by the govt., not the insurers. Maybe if the USA had a VAT, or
maybe a larger tax base, as we do, that would pay for your medical system. As it is, without political will, and politicians that are not pawns of your lobbyists, the USA will never get out from under the insurance companies" grip. They don't give a damn about YOU, all they care about is their profit margin!! Maybe you should check out Alberta, I know that they do have private clinics ther, it might be cheaper than the USA..meanwhile, man, I'm sorry you have to fight for every right you should have.....BC Bill

[Mario]

Well said Brian, What is happen in the health care business in USA is criminal. In America we have the best Government money can buy, politicians are in Gov. serving the business groups that put them in power. Legally corrupt, the most corrupt place on earth is the US of A. Wall Street, Heath Care, Banking, Insurance and all the energy companies !!!!!!!!

[john]

We just found out that ours does not pay if a polyp is removed. So tired of loopholes.
This happened with Blue Cross Blue Shield of Tx.

[Phyllis]

Did you file a grievance with your Insurance Company. I am filing one today, just found out that they say they do not cover polyp removals. They didn't wake me up to ask if I wanted them removed, So why do I have to pay for something I didn't approve.!!!!!

[Blogger Brian]

Phyllis, I was going to file an appeal, but then Regence of Oregon decided to pay for the colonoscopy and polyp removal. Here's a link to the post where I described what happened:
http://hinessight.blogs.com/hinessight/2011/05/amazing-im-finally-praising-regence-bluecross-of-oregon.html

Hopefully you'll be as fortunate. You're right: it's crazy that your insurance company won't pay when the colonoscopy succeeded in doing what it is supposed to do -- find and remove benign polyps that could turn into cancer.

[Susan Hirshorn]

I live in Montreal Quebec - the home of universal medicare. Well guess what? Preventive colonoscopies are free here if you get them at a hospital but the wait lists are over 3 years long! Only recently have doctors been recommending that people go to private clinics for them. Cost is $500. No private insurer will cover this either! My husband is one of the many people who were on that wait list (wasn't told about the private clinics). Sadly, he wasn't put to the head of the list until he already showed symptoms of colon cancer and by that time it had reached stage IV. Please let me know your progress in fighting to have insurance companies cover colonoscopies. Meantime, I plan to start my own "fight" here. Best, Susan

[Jeff Hill]

I am now finding even worse, that a benine polyp which was removed during the draining of an anal fiscular is giving the insurance company a reason for excluding Colon Cancer from my policy due to "A history of colon polyps". So i would guess the same exclusion would apply if a polyp is removed during a colonoscopy.... ridiculous.. Better check for exclusions on your policy.

[Nonnie]

So sorry this has happened to you. You are in my prayers. I guess the insurance companies are fighting the affordable care act all the way. I was diagnosed with stage 2b breast cancer in 07 my insurance Cigna is denying me a PET scan or even CT scan. Which if I don't get at least one of these my cancer could return and I risk finding it too late. This has been going on for 20 months. I hope that you have better luck fighting your insurance than I have had. GOD BLESS

[Kate Hillborne]

It is now May, 2013 and how things have changed. To clarify, it is NOT the insurance companies who are at fault here, which is a rare thing. It is the DOCTORS who are responsible for how a colonoscopy is coded--the insurance companies pay out according to how the doc coded it. Clinics and hospitals are aware the issue is being raised up the flagpole and are taking conservative positions where they code the procedure as screening (preventative) for the colonoscopy, but diagnostic if anything is found - and that is the point at which the insurance company considers the ENTIRE thing diagnostic and will not cover it.

And.. it's not just about finding polyps that shifts the coding to diagnostic. If they find internal hemmorhoids and diverticulosis...neither of which have anything to do with cancer risk...that too will be considered diagnostic, thus insurance companies will not pay. In addition, if either are found, you are now considered 'high risk' going into your next one. Turns out 95% of the population have internal hemmorhoids and most of us over 50 have diverticulosis (diverticulitis if inflammed).

The volume on this issue is being raised, so hopefully it will be resolved soon. Until then, I encourage everyone to take the time to write a letter to the Oregon Insurance Commissioner (Louis D. Savage) to say life saving procedures such as initial colonoscopies need to be covered 100% no matter what. And, to talk with the person at your insurance company who handles claims disputes, to voice your opinion there as well. We all pay hefty premiums with high deductables (ours is $7k), and absorb virtually all health care costs out of pocket simply to not have coverage the few times we need it!!!

[Peggy]

I am seriously contemplating canceling a scheduled colonoscopy for next week because I am so freaked out by the potential costs. I have no symptoms and am doing this just because I am trying to do the smart thing... it was purely by fluke that I found out about this whole polyp issue. Aetna, my insurance carrier, keeps telling me it depends on how it is coded, however at the same time, tell me if 'anything' is found it will be coded as medical. Who is the best person to 'complain' to... the insurance commissioner in my state or the cancer society, etc>

[Ted]

I had the same refusal to pay because of the coding issue. I had a polyp removed ten years ago. I checked ahead of time and both the doctor and the insurance company said it was covered 100%. The procedure was completed, nothing found and a month later I got the bill in full for the colonscopy. Oh the doctor and insurance company said we didn't know you'd already had a polyp taken out in the procedure ten yeas ago, that means all procedures after that are coded as diagnostic. six months later I got fed up with their bad treatment and denial and what was obviously a scam. I called the attorney generals office. one week after I sent the relevant papers to the attorney generals office, I received an apology from the hospital, the doctor and the insurance company, with paid in full. My insurance company,Regence Blue (double)Cross. class action suit anyone?

[Kate Hillborne]

I have a meeting scheduled with stakeholders representing various interests to identify loopholes and solutions to cost-sharing, and would love to hear from folks in Oregon who have been billed for their first colonoscopy because something was found. I called 5 facilities and all of them said they'd code my first colonoscopy as "diagnostic" if something was found. Clearly, miscoding is still an issue in Oregon and I'd like to get a sense of how pervasive it is. Thanks

[jess]

Insurance refuses to pay for mine. My mother had colon cancer my doctors informed me to get checked every 5 years. Insurance refuses to cover preventative care till I am 50!

[der]

Insurance companies are evil. They need to be eliminated.

[sharon bahnke]

my husband is going through the exact same thing right now , how dare they not cover this , we have been appealing this also , a third party is getting involved now , they will be investigating this , i will take this to rob wolcheck on national news if I have too . wish you the best of luck ,

[Mike]

I had the same problem of being charged for my "preventive" colonoscopy on both of my procedures because of polyp removal. I went round and round with my insurance company on the first one, jotting down names, dates, times, and taking detailed notes. After 6 months of this, while on the phone I said in total disgust, "This is ridiculous. I can't be the only guy you people are jacking around like this. I'm going to get a hold of an attorney and file a class action lawsuit on this." With that, the person on the phone with me said "Oh, Mr. _______, I think we have enough information to settle your case right now!" I nearly fell out of my chair! The insurance then paid for the procedure.

My second colonoscopy was a little easier because I called for pre-authorization. I kept calling in and getting different agents until I got one that told me the procedure would be covered at 100% if a polyp were found and removed, including all the lab costs. I jotted down his name and the date and time of the call. Sure enough, the insurance company tried to charge me for the procedure, but after I provided the pre-authorization info and told them they may be in violation of the Affordable Care Act, I got it covered at 100%.

I agree that the problem is the physicians and them changing the coding of the procedure from preventative. I don't know how or why they are in bed with the insurance companies with this. I think before my next colonoscopy I'll be asking the physician some detailed questions about this specific issue and how they do their coding.