ACA Preventive Benefit and Coverage of Colonoscopies

The Patient Protection and Affordable Care Act (ACA) includes provisions that require private health insurance companies to cover recommended preventive services with no patient cost-sharing, including copayments and deductibles. The recommendations that must be covered are designated A or B by the United States Preventive Services Task Force (USPSTF). Recommended services include screening for diabetes, obesity, cholesterol, and various cancers including colorectal cancer.

The requirement to cover such services took effect for new plans sold or renewed on or after September 23, 2010. In 2011, an estimated 54 million Americans received expanded coverage of preventive services under the ACA.

Screening for colorectal cancer received an A rating from the USPSTF. The Henry J. Kaiser Family Foundation, in cooperation with the American Cancer Society and the National Colorectal Cancer Roundtable, recently released a report examining how private insurers are approaching cost-sharing for screening for colorectal cancer. There are 3 circumstances when a patient may encounter unexpected cost-sharing for a screening colonoscopy: (1) when a polyp is detected and removed during a screening colonoscopy (scenario 1); (2) when a colonoscopy is performed as part of a 2-step screening process following a positive stool blood test (scenario 2); and (3) when the patient is at increased risk for colorectal cancer and may receive screening earlier or more frequently than adults at average risk (scenario 3).

The authors of the report conducted interviews with a variety of stakeholders and regulatory officials involved in the regulation of the new screening benefit. Based on the interviews, it is apparent that, under each of the 3 scenarios, there is significant variation in whether insured consumers receive colorectal cancer screening with no cost-sharing. Some of those interviewed indicated they had received more complaints relative to the issue of cost-sharing for a screening colonoscopy than for any other of the ACA’s new consumer protection provisions.

In scenario 1, when polyps are removed during the screening colonoscopy, insurers apply varying definitions of screening. According to medical experts, screening is defined by the population to which a test is applied (in the case of colonoscopy, asymptomatic individuals), not the findings that result from the test itself. According to the authors of the report, when this definition is used for a screening colonoscopy, “whether a polyp or cancer is ultimately found should not change the screening intent of that procedure.”

However, this definition is not universally applied within the medical billing and coding system and is not necessarily accepted by all health plans. Several insurers said cost-sharing would be determined by whether the patient was asymptomatic at the time of the screening even if a polyp was removed. Others said while they consider screening colonoscopies to be preventive regardless of polyp removal, their claims payment systems apply cost-sharing based on how providers code the procedure.

One medical director said, “[Polyp removal] is exactly why you are doing this…if you take that polyp out, you have prevented the cancer.” However, his plan does impose cost-sharing if the providers do not code the procedure using the Current Procedure Terminology (CPT^®) modifier 33. CPT modifier 33 was created to allow providers to identify the procedure for insurance payers, and to let providers know that the service was preventive under applicable laws, and that patient cost-sharing does not apply.

In respect to scenario 2, the USPSTF notes, “follow-up of positive screening test results requires colonoscopy regardless of the screening test used.” Insurers have varying procedures following a fecal occult blood test (FOBT) based on whether the colonoscopy is considered part of the colorectal screening exam, or a separate, diagnostic procedure.

Of the insurers interviewed for the report, 4 said they do not impose cost-sharing for a colonoscopy following a positive FOBT; whereas 3 said they always impose cost-sharing in such a situation.

Finally, in scenario 3, screening for those at an increased risk of colorectal cancer due to a personal history of colorectal cancer or adenomatous polyps is also referred to as surveillance screening, and may be coded as diagnostic despite the fact that the patient is asymptomatic. Asymptomatic adults at high risk for other reasons (family history) may also have their colonoscopies coded as diagnostic regardless of the recommendation from the USPSFT that such tests be considered screening services.

The authors of the report stated, “The federal government could issue further guidance to improve clarity and make more consistent health insurance coverage of recommended cancer screening services. It could provide additional specificity as to when consumers are eligible to receive cancer screening procedures with no cost-sharing."