Diving in on HHS' Recent FAQs on Preventive Services

A few months ago, we blogged about a report that CHIR faculty co-authored—in collaboration with Kaiser Family Foundation, the American Cancer Society, and the National Colorectal Cancer Roundtable—exploring how private insurers are covering colorectal cancer screenings, a preventative service that is supposed to be covered without cost sharing under the Affordable Care Act (ACA).

In that report, we found that there was significant confusion about how and whether to apply cost-sharing for colorectal cancer screening. Specifically, we described the variation in how cost-sharing is applied and how providers code procedures in three different clinical circumstances: 1) when a polyp is detected and removed during a screening colonoscopy; 2) when a colonoscopy is performed following a positive stool blood test; and 3) when the individual is at increased risk for colorectal cancer and may receive earlier or more frequent screening compared with average risk adults.  This variation resulted in consumers facing unexpected cost sharing and—according to regulators in some states—generated more consumer complaints than any other ACA protection. We also found that state regulators were looking to the federal government for guidance on how to address this issue.

We are pleased to report that the federal government recently offered such guidance. In a set of Frequently Asked Questions (FAQs) released last week, federal regulators addressed one of the clinical circumstances that we explored in the report: whether insurers can apply cost-sharing when a polyp is removed during a screening colonoscopy.

What does the federal guidance say? According to Question 5 of the FAQs, insurers can no longer apply cost-sharing when a polyp is removed during a screening colonoscopy. Referencing the clinical guidelines of organizations such as the American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and the Society for Gastroenterology Nurses and Associates, Question 5 noted that polyp removal is an “integral part of a colonoscopy” and, thus, insurers cannot impose cost-sharing if the polyp is removed during a screening procedure. However, federal regulators went on to note that cost-sharing can be imposed if the polyp is removed during a colonoscopy that is not a recommended preventive service.

What does the federal guidance mean? This FAQ is expected to provide additional protection for consumers by limiting the cost-sharing associated with screening colonoscopy. Thus, consumers should no longer fear that their scheduled screening colonoscopy will not be covered just because a polyp was detected and removed during the procedure. Yet, because the guidance allows cost-sharing to turn on whether a screening colonoscopy is considered to be (and accordingly coded as) “preventive” or “diagnostic,” consumers should consider asking their physician and insurer about how their procedure will be classified and why.

While the FAQ includes an important protection for consumers, it raises additional questions. First, what relief, if any, does the guidance provide for consumers that have already faced unexpected cost-sharing since the ACA went into effect in September 2010? Second, why was there such a delay in releasing guidance on an issue that has resulted in so many consumer complaints? Third, the guidance did not address the other clinical circumstances where cost-sharing rules are fuzzy: screening colonoscopy for high-risk individuals and following a positive stool blood test. Will additional guidance be forthcoming on these circumstances or will confusion continue for insurers, providers, and consumers? Finally, are federal regulators exploring the distinction between “preventive” and “diagnostic” in the context of other screening benefits under the ACA and how will future issues—such as cost-sharing for mammograms—be resolved in a clinically sound and timely manner?

CHIR plans to explore these questions and other related issues and promises to keep you posted our findings. Be sure to check in with CHIRblog for everything you need to know and, in the meantime, don’t be shy about sharing your thoughts!

8 thoughts on “Diving in on HHS' Recent FAQs on Preventive Services

  1. CHIRblog staff: In the fourth paragraph, it states, “According to Question 5 of the FAQs […],” but the FAQ linked in the third paragraph just goes to CMS’s CCIIO portal site, not to a specific FAQ, and I’ve been unable to locate the FAQ through web searches. Do you have a link to that FAQ?

      • Thank you so much, Katie! Just what I needed when speaking with our insurance company. This blog and its contents are extremely helpful — know that you’ve done good work and helped somebody out 🙂

      • During a scheduled screening procedure, a polyp was removed for examination. The hospital billed the insurance company with a diagnostic code for the entire colonoscopy, rather than a screening code. The insurance company is thus refusing to cover it under ACA because the procedure has a diagnostic code, and the hospital won’t change the procedure’s code to a screening code because of what the procedure was. Whose information in this situation needs to be corrected? It’s currently a run-around between hospital and insurance, with each saying the other is to blame, and neither taking responsibility.

        Per what the CMS website says, “the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure.” However, all the insurance company is seeing is a diagnostic code, not details of the procedure. Is there maybe an ICD9/10 code for screening-that-becomes-diagnostic procedure?

  2. I would also like to know the answer to this. I’ve been putting off getting a colonoscopy for a year or so, and was very exciting to hear about the HHS closing of the loophole. But still fear what happened above will happen to me if the hospital (or doctor) decides to code a polyp removal during a preventive screening, as “diagnostic.” Do I need to get something in writing, in advance?

    • Hi Mark – thanks for your comment! I understand your concern because cost-sharing for colonoscopies can be quite high. You might consider speaking with both your insurer and provider (hospital/doctor) to understand their policy on coding preventive procedures versus diagnostic procedures. Much can depend on how the procedure is coded (as well as making sure that your plan is not a grandfathered plan, meaning it has to meet the preventive services coverage requirement under the ACA). While there are codes that insurers and providers can use, the problem is that there is a lot of variation. For more on the specifics of the coding, see our report on page 17 http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8351.pdf. For example, you could ask the provider if they use “CPT modifier 33” for colonoscopies and then confirm with the insurer that they credit this type of code. It’s a very confusing world to navigate and I truly hope this helps!

  3. I recently had a screening colonoscopy, and was happy that no polyps were found, so I expected no cost sharing. I had a large cost sharing, because the insurance carrier said it was coded as a “high risk” screening because of the history of polyps. If this is true, I will never be without cost sharing for a screeing colonoscopy? It was coded with a G0105, and reconfirmed with the facility that it must be coded that way because of the history. I would have been better off if they had found a polyp as far as the cost sharing! Does anyone have any insight on this?

    • Hi Joan – thanks for your comment! We’ve heard from a number of consumers about the issues you’ve raised with respect to being considered “high-risk.” We explored this situation in the report but, unfortunately, it continues to be a barrier for many consumers.