Fri, Jan 17 2014
The new health-care law encourages people to get the preventive services they need by requiring that most health plans cover cancer screenings, contraceptives and vaccines, among other things, without charging patients anything out of pocket. Some patients, however, are running up against coverage exceptions and extra costs when they try to get those services.
Advocates and policy experts agree that more federal guidance is needed to clarify the rules.
Rebecca Hyde of Woodstock, Conn., was angry when, after getting a colonoscopy to screen for cancer in December, she got a notice that her insurer was charging a hospital "facility fee" of $1,935 against her $6,000 deductible. Such fees are not uncommon for hospital-based care
But since colonoscopies are recommended starting at age 50, the 53-year-old had not expected to owe anything out of pocket.
"I thought it was the bait-and-switch: They tell you it's going to be preventive and then you get a really large bill," she says.
Hyde discussed the problem with hospital billing staff, who offered to resubmit the bill using a different procedure billing code. Hyde says she hopes the issue can be resolved without having to appeal to her health plan.
Hyde's experience is not unique, says Mona Shah, associate director of federal relations at the American Cancer Society Cancer Action Network. Other patients have reported being charged for services related to a colonoscopy, if not the actual screening itself. Last year, federal officials clarified that insurers can't impose cost sharing if a patient has a polyp removed during a screening colonoscopy, as Hyde did.
But the rules are murkier for other services. As in Hyde's case, it's often a problem with how a procedure is coded for billing purposes, Shah says. Instead of a single code that covers a procedure and everything related to it, the traditional fee-for-service system assigns multiple codes: one for the colonoscopy, for example, and others for the anesthesia and the facility.
"We're trying to get [the Department of Health and Human Services] to release guidance that says prevention should cover all related services," she says.
HHS spokeswoman Joanne Peters says the agency continues "to monitor how the preventive services provisions are being carried out, and we are working with stakeholders to ensure they understand our guidance and to offer further clarity to them when needed."
Lacking explicit federal guidance, "there may be some variation in coverage," says Susan Pisano, a spokesperson for America's Health Insurance Plans, a trade group. But "our plans are committed to doing what the [health law] says we should do."
Under the health law, preventive services are covered without patient cost sharing if they are recommended by the U.S. Preventive Services Task Force, an independent group of medical experts that evaluates scientific research and makes recommendations about clinical preventive services. Other preventive services are also covered without cost sharing, including recommended vaccines and services related to women's and children's health.