Passage of the Affordable Care Act marked a major victory in the fight against cancer. The law waived the coinsurance and the deductible for many cancer screening tests, including colonoscopy, sigmoidoscopy and fecal occult blood testing (FOBT), which screen for colorectal cancer. However, due to the nature of colonoscopy, many patients still wind up paying out of pocket for screening colonoscopy.
Colonoscopy is a unique screening test because gastroenterologists are able to remove precancerous polyps and small cancers during the screening procedure. Under Medicare, removal of polyps reclassifies the screening colonoscopy as a diagnostic procedure for which patients must pay coinsurance. This means Medicare beneficiaries can go to the gastroenterologist for a colonoscopy assuming it’s free, only to receive a bill after the physician finds and removes a suspicious polyp. Many private insurance companies follow Medicare rules, and thus similar problems can occur to patients insured through private insurance companies.
Cost-sharing creates financial barriers, which discourage the use of recommended preventive services. Cost-sharing should not be a barrier to screening colonoscopy.
If your insurance company charges you for a screening colonoscopy, you can appeal it. Remind them that under the Affordable Care Act, screening colonoscopies should be covered in full, whether a polyp is found or not.
Here are three steps you can take to appeal a diagnostic charge:
- Contact your doctor to confirm the procedure is coded as a screening.
- Contact your insurer to express your desire to appeal the diagnostic charge.
- If your appeal can’t be addressed over the phone, use this colonoscopy sample appeal letter, courtesy of the National Women’s Law Center. Call your insurer to find out where to send your appeal.