Under the Affordable Care Act, certain high-value preventive services – such as colonoscopies – are supposed to be free. No co-pay for the patient.
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.
Instead, Branstetter has found, EMSA has followed a number of apparently deceptive billing practices, including sending bills that list a “due from patient” balance of something like $1,100, even though that amount is actually covered by the utility fee. It also unilaterally implemented a policy making patients responsible for the balance if they don’t provide insurance information within 60 days, while providing lavish benefits to employees and executives.
“It’s a paradigm shift from what most consumers are used to at their doctor’s office,” says Red Gillen, a San Francisco-based analyst with consulting firm Celent, who last month published a report on doctors seeking upfront payment from their patients. Gillen says that until recently, insurers paid so much of the cost of medical care that medical providers, including doctors, labs and hospitals, focused their fee recovery efforts on the companies. But in the past few years, Gillen says, employers and insurers have shifted more costs to consumers in the form of higher co-pays, higher co-insurance and higher deductibles, making those payments an increasingly large share of doctors’ incomes. According to Gillen, consumer out-of-pocket spending as a percentage of all health-care spending rose to 12 percent last year, and is expected to continue rising.
Patient advocates regard the faster billing process as a positive for consumers, Lunzer Kritz found, but some are concerned that patients are not warned about their doctor’s billing practices and that higher up-front payment demands may discourage sick people from seeking care.