Preventive care: It's free, except when it's not

Yahoo News

By CARLA K. JOHNSON | AP – Wed, Dec 28, 2011

CHICAGO (AP) — Bill Dunphy thought his colonoscopy would be free.

His insurance company told him it would be covered 100 percent, with no copayment from him and no charge against his deductible. The nation's 1-year-old health law requires most insurance plans to cover all costs for preventive care including colon cancer screening. So Dunphy had the procedure in April.

Then the bill arrived: $1,100.

Dunphy, a 61-year-old Phoenix small business owner, angrily paid it out of his own pocket because of what some prevention advocates call a loophole. His doctor removed two noncancerous polyps during the colonoscopy. So while Dunphy was sedated, his preventive screening turned into a diagnostic procedure. That allowed his insurance company to bill him.

Like many Americans, Dunphy has a high-deductible insurance plan. He hadn't spent his deductible yet. So, on top of his $400 monthly premium, he had to pay the bill.

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Breast cancer screenings can cause confusion too. In Florida, Tampa Bay-area small business owner Dawn Thomas, 50, went for a screening mammogram. But she was told by hospital staff that her mammogram would be a diagnostic test — not preventive screening — because a previous mammogram had found something suspicious. (It turned out to be nothing.)

Knowing that would cost her $700, and knowing her doctor had ordered a screening mammogram, Thomas stood her ground.

"Either I get a screening today or I'm putting my clothes back on and I'm leaving," she remembers telling the hospital staff. It worked. Her mammogram was counted as preventive and she got it for free.

"A lot of women ... are getting labeled with that diagnostic code and having to pay year after year for that," Thomas said. "It's a loophole so insurance companies don't have to pay for it."

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Cindy Holtzman, an insurance agent in Marietta, Ga., is telling clients to check with their insurance plans before a colonoscopy so they know what to expect.

"You could wake up with a $2,000 bill because they find that little bitty polyp," Holtzman said.

Doctors and prevention advocates are asking Congress to revise the law to waive patient costs — including Medicare copays, which can run up to $230 — for a screening colonoscopy where polyps are removed. The American Gastroenterological Association and the American Cancer Society are pushing Congress fix the problem because of the confusion it's causing for patients and doctors.

At least one state is taking action. After complaints piled up in Oregon, insurance regulators now are working with doctors and insurers to make sure patients aren't getting surprise charges when polyps are removed.

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