Colonoscopies are key for early detection. So why are some struggling to get them covered?
BATH (WGME) -- It's become a health care headache for a Maine family after they got an unexpected bill for a routine cancer screening.
Colonoscopies are considered key for early detection, but the CBS13 I-Team has found some Mainers are struggling to get the procedure fully covered.
"I guess you could sum it up under laws and loopholes," Kimberly Gardner, who brought the issue to the I-Team's attention during our recent "Ask" event in Bath, said. "We ran into difficulty and were told by our insurance agent that she's run up against this before."
Gardner's husband Delbert had recently gone in for a colonoscopy, recommended by his doctor, at Mid Coast Hospital. This wasn't the first time he's gone in for a colorectal screening, but it was the first time he's received a bill afterward.
"They encourage senior citizens to get all the routine preventative screening care, mammograms and colonoscopies, saying, 'Go do it, it's free, the screen is covered,'" Gardner said. "We did not think that there were going to be any charges at all."
Typically, colonoscopies are recommended every 10 years starting at age 45. According to the CDC, colonoscopies remain the most effective way to reduce a person's risk of colorectal cancer.
However, for people consider to be at higher risk, or have a history of polyps being found like Delbert, more frequent screenings are recommended.
While the Affordable Care Act (ACA) requires both private insurers and Medicare to cover the costs of colorectal cancer screenings, experts say insurers and providers still have some wiggle room when it comes to cost sharing, especially if a polyp is found during the procedure.
"Medicare patients, unfortunately, are still facing this out of pocket cost," Fight Colorectal Cancer Vice President of Advocacy Molly McDonnell said. "The kind of teeth to it don't always exist, and sometimes insurers are still able to put the cost sharing in place and some patients just end up paying it."
The Gardners were on a Medicare Advantage plan at the time with Wellcare Insurance. According to their bill, the plan covered more than $1,300 of the total cost, but because a polyp was found and removed, the remaining costs were shifted to the Gardners.
It's a tactic advocates believe is happening all too often. However, thanks to a law passed as part of the 2021 Consolidated Appropriations Act, those costs are slowly decreasing for those on Medicare.
"By 2030, ultimately that cost sharing will go away completely," McDonnell said. "But in the interim time, each year it's going down by a certain amount."
This year that cost sharing is down to 15 percent. In 2027 it will drop to 10 percent and finally go away completely in 2030.
While the Centers for Medicare and Medicaid Services have continued to clarify that screenings should be fully covered, even if a polyp is found, advocates say those at a higher risk of cancer are still not always protected by those guidelines.
"There's sort of this gray area and lag between what insurance regulation says and what coding says," McDonnell said. "So it ends up being this ultimately confusing mess for both patients and providers."
Wellcare Insurance, nor its parent company Centene, did not respond to the I-Team's multiple requests for comment for this story.
As for MaineHealth, which operates Mid Coast Hospital, a spokesperson wouldn't comment on the Gardner's specific case but said they follow guidelines set by various federal agencies when it comes to coding for procedures.
“While we cannot comment on the specifics of any one patient’s care, generally coding is based on guidelines set forth by various agencies, including the Centers for Medicare and Medicaid Services, the Centers for Disease Control, the National Center for Health Statistic and others," the spokesperson said. "Once a procedure code is established, whether and to what extent that procedure is covered is determined by the patients’ insurance carrier.”
Colorectal screenings can be labeled as either a "screening" or diagnostic" procedure. Advocates say the decisions related to coding for either label is often debatable but can make all the difference for what a patient ends up paying.
CBS13 I-Team Reporter Dan Lampariello: "Do you worry that out-of-pocket costs added on to something like this could lead to people not wanting to be screened?"
McDonnell: "Absolutely. I think we've seen that, that is a very legitimate barrier."
Barriers patients like the Gardners believe need to be broken down.
"Is this really what they wanted, is this really what they intended?" Gardner said. "When something is bad you say, 'Well there should be a law against that, and that's what we have our legislators for.'"
There is a piece of legislation before congress right now that would help close up the coverage loophole for Medicare patients before 2030. It was introduced by the late Congressman Donald Payne Jr. (D-New Jersey).
Both Rep. Jarden Golden (D-Maine) and Rep. Chellie Pingree (D-Maine) tell the I-Team they would support the bill if it were to come up for a vote on the House floor.
“Congressman Golden was not aware of this specific case but has long held that Medicare should be affordable and preventative care should be covered, particularly when Mainers need it most." a spokesperson for Golden said in a statement.
"Congresswoman Pingree was a longtime cosponsor of a bill (H.R. 1570) to fix the cost sharing loophole and waived coinsurance requirements with respect to colorectal cancer screening tests, regardless of the code billed for a resulting diagnosis or procedure," a spokesperson for Pingree said. "Congresswoman Pingree, who is saddened to hear of Rep. Payne’s passing, would be supportive of his bill to implement this coverage immediately if it came to the floor for a vote."
ADVICE FOR PATIENTS
While many patients may not expect to see a bill after a procedure, there are some steps you can take to make sure you're not caught off-guard.
Experts say it always pays off to be vocal before a procedure. If you go in for a colonoscopy, remind your provider of the government's interpretation of the Affordable Care Act and that it should be considered a screening regardless of weather a polyp is found.
It's also a good idea to contact your insurance provider prior to any procedure to ask about what your plan may cover and if there's any potential for cost sharing.
Under the new "No Surprise Act," providers are also now required to give you an estimate of any potential out of pocket costs before a procedure.