‘Free’ preventive care can cost patients big money [Ventura County Star, Calif.]

Jan. 29--Patients are getting charged as much as $3,000 for screenings they thought would be free under a federal health care reform mandate that promises free preventive care.

The year-old provision compels new insurance policies to cover colonoscopies, mammograms, blood pressure screenings, HIV tests and many other procedures aimed at early detection of health problems, with no co-pays or deductibles. But doctors say the requirement -- designed to make it easier to get care -- may morph into a roadblock because some patients are getting billed when certain preventive procedures reveal growths that could become cancer.

"I think it stinks. The ludicrous thing is the reason you do screening is to find something," said Dr. Jack Rotenberg, an Oxnard digestive system specialist, suggesting that charging people when problems are diagnosed is the definition of bait and switch.

Most of the problems revolve around colonoscopies -- screenings designed to detect colon and rectal cancers that kill about 52,000 Americans a year.

The procedure has been covered by federal health care reform for men and women 50 and older since September 2010, although many older insurance policies are exempt from the new provision.

Some patients are still receiving bills for deductibles or co-pays when the procedures show an abnormal growth called a polyp that can develop into cancer.

When doctors remove a polyp during a colonoscopy, the procedure is often defined as diagnostic and not preventive. That means Medicare and many private insurers ask patients for fees that, depending on policy terms and facility fees for surgery centers, can range from a nominal fee to $3,000.

"They're told they have full coverage and they get a $300 bill. I've had one patient say, 'Can you put it (the polyp) back?' " said Dr. Gilbert Simoni, a Thousand Oaks gastroenterologist who contends insurers are implying doctors should delay removing the polyp.

"I think it's crazy," he said. "I'm not going to look at something that could potentially become cancer and tell the patient to go home for two weeks and come back."

Representatives for Anthem Blue Cross and the California Association of Health Insurance Plans referred questions on preventive care to a national trade organization, America's Health Insurance Plans. Officials there acknowledged the problem and blamed it on the way doctors communicate with insurers.

Insurance companies may charge for screenings or tests if patients show symptoms of cancer or are going through a colonoscopy as a follow-up to an earlier diagnosis, said Robert Zirkelbach, spokesman for the trade group. But many insurers consider colonoscopies to be preventive care -- and covered -- regardless of whether polyps are present, he said. Bills are sent when they aren't told the nature of the procedure.

"One of the challenges is: How are those procedures being coded by physicians?" he said. "Is it clear that it's a preventive service?"

He called on the federal government to hold a hearing on the issue to provide guidance on medical coding and make sure insurers and doctors are on the same page.

Some doctors, however, insist the issue isn't coding, but rather money and the insurers' desire for it.

"That is subterfuge," said Dr. Paul Sanders, a Thousand Oaks gastroenterologist, contending insurers are shifting blame from themselves to physicians. "It's utter baloney. The insurance companies have quite intentionally blocked any way that anybody could understand what they're going to, and not going to, pay for."

Zirkelbach refuted suggestions that insurers are gaming the system, noting his organization predicted issues with medical coding even before the health care reform law began.

And if patients are billed for colonoscopies in which polyps are removed, the patients should talk to the doctor and the insurer, he said.

Doctors vary on how often problems emerge. Rotenberg of Oxnard said complaints are more the exception than the rule. Others say problems occur almost every time polyps are detected.

"In 20 or 30 percent, we do find things," said Simoni, referring to polyps or other growths. "These are things we have to remove. So we do that, and it automatically becomes, 'Your doctor removed your polyp, so it's not screening anymore. You're going to have to pay.' "

Dr. Robert Lum, a radiation oncologist from Oxnard, said he's seen patients billed for mammograms because the screenings revealed something.

"They actually get charged more," he said. "Even if it turns out actually to be nothing, it's no longer considered screening."

A spokesman for the California Department of Managed Health Care urged people who receive bills for preventive care to contact the state agency. He said the office has received about 100 complaints involving bills for preventive care since the federal health care reform provision began in September 2010.

Representatives of the American Society for Gastrointestinal Endoscopy blame the problems in part on government regulations involving the difference between preventive and diagnostic care. They're pushing Congress for changes that assure colonoscopies are free to patients, regardless of polyps. Efforts also should focus on making sure all doctors explain to patients that they may get billed for colonoscopies, said Laurie Sobel, a senior attorney with the Consumers Union group that works to protect consumers.

Patients also should not be charged for an entire visit but only for the part of a procedure in which a growth is removed, Sobel said.

Charles Rosen, a Simi Valley insurance broker and president-elect of the California Association of Health Underwriters, tells clients to minimize chances of any billing confusion by not talking to a doctor about any health concerns during a screening exam.

"If you have a pending issue, make another appointment," he said.

Some people agree with the advice. Others contend the doctor-patient relationship depends on trust, which disappears when patients delay reporting problems.

"I think that's the worst instruction or advice you could give patients -- to not be truthful," said Simoni, thinking of conditions that could be linked to bleeding or constipation. "It's dangerous. God forbid the patient has something that's not revealed."

Some patients were reluctant to complain about the situation. A 53-year-old homemaker from Agoura Hills worried that using her name would affect her insurance coverage.

She suffers from an inflammatory bowel disease and is worried the colonoscopy she had this month will be interpreted as therapeutic and won't be covered.

"I have a $5,900 deductible," she said, worrying her bill will be frighteningly close to that number. "I'm going to have to pay almost all of that. I don't have it."

Because of her condition, she's supposed to undergo colonoscopies every two years. Lack of money means she waited six years.

The free preventive care provision covers many services for people at higher risk for certain illnesses, including cancer screenings for smokers. But the Agoura Hills woman is convinced it would be easier for her to get coverage for a colonoscopy if she didn't have symptoms that make her more vulnerable.

"It's insane," she said, suggesting people who need the tests most are the ones who are asked to pay. "It should be the other way around."

___

(c)2012 Ventura County Star (Camarillo, Calif.)

Visit Ventura County Star (Camarillo, Calif.) at www.vcstar.com

Distributed by MCT Information Services