BIG TIMBER — Carmen Hodges wasn’t going to get a colonoscopy screening this year until she received a letter from her insurance company urging her to “take advantage of preventive benefits paid at 100 percent.”
Surely there must be a mistake, she thought. So, she read further. “This means you’ll pay no deductible or co-insurance for these services — saving you money.”
The nation’s new Affordable Care Act requires most insurance plans to cover all costs for preventive care, including colon cancer screening. So Hodges, 57, had the procedure in November.
Then the bill arrived: $3,535.
“I’m frustrated,” Hodges said. “I’m angry. I think the letter was untruthful. I would never have done it, not with our finances and the economy the way it is.”
Hodges and her husband, Dave, own and operate Hodges Fine Art in Big Timber. They refused to pay the bill and fought it. The couple calls what happened to them a “bait and switch.”
During the colonoscopy, her doctor removed two noncancerous polyps, turning her so-called free screening into a costly diagnostic procedure.
“They do it right then, so it’s not like you have a choice,” Hodges said.
Because the screening turned into a procedure, Hodges’ insurance company billed her and so did the hospital.
She had her procedure at Billings Clinic and harbors no ill will toward the hospital or her physician. “He’s great,” she said of her doctor.
At Billings Clinic, part of the education process before a colonoscopy is to encourage every patient to watch an educational video. Topics in the video include a description of a polyp, why it is removed, how it is removed, and the process of sending the tissue to the lab and reporting the results. The Clinic has a release form the patient must sign about the procedure, but it does not contain specific language giving the physician permission to remove any polyps found during the procedure.
“This discussion takes place verbally in a discussion between patient and physician,” said Dr. Steven Hammond, a gastroenterologist at Billings Clinic. He did not perform Hodges’ procedure.
A patient could theoretically ask his or her physician not to remove any polyps discovered during the screening, although the purpose of a screening is partly to look for polyps.
“We do not really know if polyps are malignant or have a high risk of malignancy without removing them and having the tissue looked at by the pathologists,” Hammond said. “There is no point in undergoing a colonoscopy for screening (no symptoms) if polyps aren’t removed and masses biopsied.”
The size and appearance of a polyp can help doctors judge the likelihood of the polyp being high risk, but standard practice is to remove them unless there is some contraindication, Hammond said.
Research reported Feb. 21 in the New England Journal of Medicine shows that a colonoscopy saves lives. The research found that removing precancerous polyps spotted during a colonoscopy, a standard procedure today, dramatically cuts the chance of dying from the disease. The study followed 2,602 patients who had the suspicious growths removed during the test over a median of 15.8 years. It underscores the importance of removing the polyps.
The new health care law encourages prevention by requiring most insurance plans to pay for preventive care. As a result, about 166,000 Montana residents received at least one new, free preventive service in 2011 through their private health insurance plan, according to Health and Human Services Secretary Kathleen Sebelius. And, an estimated 115,000 Montana residents with Medicare received at least one preventive benefit in 2011, including the new Annual Wellness Visit, according to Sebelius.
Nationwide, the Affordable Care Act provided approximately 54 million Americans with at least one new free preventive service in 2011 through their private health insurance plans. And an estimated 32.5 million people with Medicare received at least one free preventive benefit in 2011, including the new Annual Wellness Visit, since the health reform law was enacted, according to Sebelius.
But there is a downside, as Hodges discovered.
“They sugarcoat these letters and suck people in,” said Dave Hodges, 62, “There was no indication and no stipulation saying we’d have to pay if they found something.”
Michael Kananen, a Boyd-based insurance broker for several big-name insurance companies, has more than 6,000 clients, including the Hodgeses. Kananen said he receives complaints similar to that of the Hodgeses every day, sometimes two a day. He blames health care reform and hospital billing departments that don’t know the difference between a preventive screen and a procedure.
Of the clients who seek a colonoscopy screening and are charged, at least 25 percent contest the charge, his bookkeeper said. Of those, about half win their claim.
“It’s a big mess, honestly,” Kananen said. “It’s a big freaking pain in the butt. The average person out there doesn’t know what the hell they’re doing. It’s all new for everybody.”
Generally, Kananen said, if your coverage went into effect after health care reform passed on March 23, 2010, the full cost of preventive care — things like annual checkups, flu shots and cancer screenings like mammograms and colonoscopies — should be covered without a co-pay or co-insurance.
There are still some health plans that are exempt from covering preventive care in full, he said, so be careful. If your plan hasn’t made huge changes to its benefit package since health reform took effect, it has “grandfathered” status and is not required to comply with this provision of the health reform law, Kananen said.
State Auditor Monica Lindeen, whose office regulates the insurance and investment industries in Montana, said she has received similar complaints from residents who were billed for so-called free screenings. Consumer representatives for her office say they have had fewer than 10 complaints since the provision took effect.
“It’s probably due to the fact that few people think to call the state auditor with this kind of problem,” said Lucas Hamilton, Lindeen’s communication director. “We’re working hard to correct that.”
Lindeen said she does not believe the confusion is intentional. The Affordable Care Act is abundantly clear in that preventive care is provided at no cost, while diagnostic care can be cost-shared. She said educating both consumers and hospitals is essential to eliminating the confusion.
A December public opinion poll conducted by the Kaiser Family Foundation, based in Menlo Park, Calif., reported that 42 percent of Americans are unsure of how health reform will affect them and their families.
She implores consumers to learn what is covered and what isn’t because, despite the confusion, there is still a lot of benefit to the health care reform.
“Some 54 million people have already benefited from the Affordable Care Act,” Lindeen said.
Some physicians and prevention advocates are asking Congress to review the law to waive patient costs, including Medicare co-pays, which can cost up to $230 for a screening colonoscopy where polyps are removed. The American Gastroenterological Association and the American Cancer Society are pushing Congress to fix the problem because of the confusion it is causing for patients and doctors.
Breast cancer screenings are also causing some confusion in other states for similar reasons, although not in Montana because the state’s law is clear when it comes to mammograms, according to Lindeen and Kanenen, who rarely gets a complaint about mammogram screenings.
Montana law requires that insurers provide first-dollar coverage, meaning your health insurance company will cover health care expenses without you having to pay copayments or deductibles first, for mammograms according to specific guidelines, including:
One baseline mammogram for a woman between age 35 and 39.
A mammogram every two years for any woman between age 40 and 49, or more frequently if recommended by the woman’s physician.
And a mammogram each year for a woman who is 50 or older.
While the law sets minimum coverage at $70, some insurers had voluntarily increased the benefit to cover the full cost of a mammogram well before the implementation of the Affordable Care Act.
Some grandfathered insurance plans may still be operating under the Montana mandate rather than the federal mandate. In that situation, a patient would still have to receive the minimum benefit according to Montana law but could be responsible for paying the rest of the cost of the mammogram.
After months of fighting with the insurance company and the hospital, Carmen Hodges’ bill has been paid in full.
“It’s a really good thing but we hadn’t kept after both of them, we would have had to pay that out of pocket,” Dave Hodges said. “Neither side was very easy to deal with. It’s good to everybody to know what’s going on with this so-called preventive care and screening.”