|By Tom Kisken, Ventura County Star, Calif.|
|McClatchy-Tribune Information Services|
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.
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
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
"They're told they have full coverage and they get a
"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."
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
"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.
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
"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.' "
"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
Representatives of the
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.
"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
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
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
"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.)
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