An article in Kaiser Health News described how people who receive preventive medical services often billed for services that were supposed to be free. This is especially interesting since I will probably schedule a colonoscopy this year. Colonoscopies are supposed to be a (free) preventive service under the Affordable Care Act.
Memorial Day weekend I was at a family gathering and a family member told me this exact problem happened to her. She went in for a colonoscopy and received a bill for nearly $3,000. Here is what happened to her and to Elizabeth Melville, the lady interviewed in the Kaiser Health News article. Under Obamacare you are allowed one free wellness screening visit each year. In addition, preventive care is not subject to deductibles or cost-sharing. What is considered preventive services is somewhat determined by the recommendations of the U.S. Preventive Services Task Force. The Task Force is made up of an independent panel of experts in primary care and prevention. For example, the Task Force recently overturned decades of conventional wisdom that people over 60 should take a baby aspirin every day for cardiac health.
Here is the rub: if you suspect something is wrong with you it becomes diagnostic rather than preventive. Patients need to be careful how they discuss preventive care with their doctors when seeking care they expect to be free. Let’s assume you go to see your doctor and say, “Doc, I have a family history of colon cancer and I had polyps removed five years ago during my last colonoscopy. Should I schedule another colonoscopy?” This example would likely fall into the category of diagnostic medical services rather than a preventive medical service. Diagnostic services are subject to cost sharing and once it’s coded that way and billed to the insurer it is hard to change. On the other hand, you’re probably good if you talk to your doctor and say, “I’m in perfect health. I don’t have any valid reason to seek a preventive service. Oh, I wonder if it isn’t time to schedule a colonoscopy?”
In the Kaiser Health News article both Elizabeth Melville and her husband had colonoscopies days apart. Both had polyps removed during a previous colonoscopy. Elizabeth Melville had a polyp removed during her latest procedure while her husband was polyp free. Both were also receiving their second colonoscopy less than 10 years after their first, something of a red flag to a health plan. The Melvilles were covered under the same plan but the fact she had a polyp removed less than 10 years since her last colonoscopy was enough to render her procedure diagnostic rather than preventive. She was billed, her husband was not.
So basically, if you have an elevated risk or are experiencing symptoms that prompted you to enquire about a preventive service you are better off not discussing those symptoms with your physician. That is sad because information is essential in helping your physician better care for you.
When I schedule my colonoscopy this summer, I better not mention any reason that theoretically might have prompted me to finally schedule a procedure people dread having performed. Also, when I schedule my annual worthless wellness screening exam I need to make it clear this is my annual worthless wellness exam and I won’t be discussing anything relevant to my health during this exam. A single question by the patient or the doctor can very easily turn a free annual worthless wellness examination into an office visit for a medical problem that requires cost-sharing. Yes, this is ridiculous and renders the visit worthless. What’s more, my doctor earns more money by coding visits as treatments rather than wellness. He or she may not even be willing to schedule the worthless Wellness visit.