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.
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.