Patients paying for confusion over prevention vs. treatment under ACA

Joanne Kenen

About Joanne Kenen

Joanne Kenen, (@JoanneKenen) the health editor at Politico, is AHCJ’s topic leader on health reform and curates related material at She welcomes questions and suggestions on health reform resources and tip sheets at Follow her on Facebook.

Under the Affordable Care Act, certain high-value preventive services – such as colonoscopies – are supposed to be free. No co-pay for the patient.

Core Topics
Health Reform
Oral Health
Other Topics

But some patients are getting charged when they don’t expect it and perhaps shouldn’t be.

And there is a lot of inconsistency on who gets charged, depending on individual circumstances, what state they live in and what health plan they have. Part of it is confusion about what constitutes “screening” and what constitutes treatment. Plus doctors vary in how they “code” and bill for these services.

The variance is not just based on the individuals’ health circumstances (i.e. whether they had a polyp or not), but what state they live in, what health plan they have. The whole thing is generating confusion and complaints – and it’s a good story.

The thinking behind making preventive care free – specific preventive services, graded A or B by the U.S.  Preventive Services Task Force (USPSTF) – is that it makes it more accessible. It’s easy to put off – and put off and put off – screening. Research has shown that having to pay for it is an additional barrier.

The Kaiser Family Foundation, the American Cancer Society and the National Colorectal Cancer Roundtable just put out a report examining the problem. Three scenarios seem common:

  1. Sometimes patients are charged because a polyp is detected and then removed during the colonoscopy – which can be seen as crossing from screening to treatment.
  2. Sometimes people are charged if they are screened more frequently than the usual recommendations, because of risk factors such as family history.
  3. And sometimes people are charged when they have the colonoscopy after having a positive stool blood test.

The report finds lots of confusion – and variation. Two patients with very similar medical profiles could have very different financial outcomes. It varies by state – and even by health plans within a state. It’s generating confusion and discontent. (Just what the health law needs, right?)

So what’s the story for you?

What’s happening and who is it happening to? Advocacy groups, consumer assistance programs, gastroenterologists and state or local cancer association affiliates may be able to help.

What criteria are doctors using – and how much variation do they encounter as they deal with different insurers? Or do health plans find that the physicians they do business with code these procedures differently? In other words, is it the health plan or the doctors creating the confusion?

Have state regulators started looking at it?  How about the state legislature? Connecticut has passed a law requiring more consistency in colonoscopy billing, effective in January 2013. A few other states are looking at remedies; see details in the Kaiser report. Some states have been waiting for more federal guidance on what constitutes “prevention” versus “treatment” but that hasn’t happened yet.

What’s the gap between what patients are told and what they are billed? How many doctors even know the law? Who is communicating it to them?

Is this a problem with other screenings – mammograms, obesity management? Who is complaining and who is responding?

Joanne KenenJoanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to

There are more details in the report that may be relevant to your community. Also, see this New York Times article from last spring that explores a separate – but related – issue of the unexpected costs of anesthesiology from colonoscopy. The Kaiser report didn’t get into this, but it’s worth asking about as you report on preventive coverage.

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.