Asinine, Backasswards Colonoscopy Insurance Rules Make Patients Decline Medically Necessary Testing

I’ve had several telephone calls in the last two weeks from a 40-year-old woman with abdominal pain and changed bowel habits. She obviously needs a colonoscopy, which is what I told her when I saw her.

If she needed an MRI to rule out a brain tumor I think she would accept that there would be co-pays or deductibles, because the seriousness of our concern for her symptoms would make her want the testing.

But because in the inscrutable wisdom of the Obama Affordable Care Act, it was decided that screening colonoscopies done on people with no symptoms whatsoever are a freebie, whereas colonoscopies done when patients have symptoms of colon cancer are subject to severe financial penalties.

So, because there’s so much talk about free screening colonoscopies, patients who have symptoms and need a diagnostic colonoscopy are often frustrated, confused and downright angry that they have to pay out-of-pocket to get what other people get for free when they don’t even represent a high risk for life-threatening disease.

But, a free screening colonoscopy turns into an expensive diagnostic one if it shows you have a polyp and the doctor does a biopsy – that’s how the law was written. If that polyp turns out to be benign, or hyperplastic, there is no increased cancer risk associated with it, but you still have to pay your part of a diagnostic colonoscopy bill because they found something.

For those who don’t know:

A “precancerous“ adenomatous polyp has only a 2% risk of actually turning into a cancer. So screening colonoscopies, while they make some sense on the population level, are less obviously a statistically good deal for the majority of people who have them if you consider the out of pocket cost when something is found.

Cologuard, the noninvasive screening test, sounds like a good deal but a positive test result represents no disease at all 50% of the time and non-cancerous conditions about 45% of the time. And if you have a positive Cologuard, the subsequent colonoscopy is technically definitely a diagnostic colonoscopy subject to all the financial penalties people are so upset about.

So, my 40-year-old woman with colon cancer until proven otherwise keeps calling me, saying she won’t have the colonoscopy unless I can make sure it’s billed as a screening colonoscopy.

Well, traditional guidelines have been to start screening at age 50, and now there is a movement to start screening at age 45 because colon cancer is seen in many younger people now. You can also qualify for a screening colonoscopy 10 years before a first-degree relative developed colon cancer.

Those are the rules. I didn’t make them up. Somebody working for Obama did.

In the area where I practice, there are no gastroenterologists. General surgeons are the ones who do colonoscopies. And unlike big city gastroenterologists (Bangor, Maine) our local surgeons meet with the patients first to take their history and establish the need for and classification of the colonoscopy.

We have urged my patient to at least go and talk with the surgeon. That will not cost $5,000 but will hopefully make her understand her situation better.

This is what I call Metamedicine. I know what my patient needs, but how do I get her there? What are all the bureaucratic and financial obstacles standing between me and my patient on one hand, and what we both agree she needs to have done on the other?

22 Responses to “Asinine, Backasswards Colonoscopy Insurance Rules Make Patients Decline Medically Necessary Testing”

  1. 1 Kelley January 17, 2020 at 9:15 am

    Hans I face this same issue almost daily with patients!!!!! I wonder did Obama ask the advice of any country docs before setting into place his horrible plan ? Ugh

    Hope you’re well up there in Gods country
    I miss it

    Kelley Guthrie

  2. 2 Paul Terrill, MD, FAAFP January 17, 2020 at 9:48 am

    As a Family Physician who performs colonoscopies for our remote rural community, I field a lot of the questions you address here. While we can disagree on the benefits of colon cancer screening, it is important to note that ACA coverage for screening is not as you state it. From the American Cancer Society: “Soon after the ACA became law, some insurance companies considered a colonoscopy to no longer be just a ‘screening’ test if a polyp was removed during the procedure. It would then be a ‘diagnostic’ test, and would therefore be subject to co-pays and deductibles. However, the US Department of Health and Human Services has clarified that removal of a polyp is an integral part of a screening colonoscopy, and therefore patients with private insurance should not have to pay out-of-pocket for it (although this does not apply to Medicare, as discussed below).” I get plenty of patients that decline medically necessary testing for fear of the costs that have nothing to do with others getting the same procedure for “free.” Human nature creates excuses for not doing the wise thing in all sorts of situations. They are just excuses, nothing more.

  3. 3 notesfromthebayofplenty January 18, 2020 at 3:26 pm

    I went through the same thing with the unilateral mammogram that I have had in the years since my first screening mammogram picked up breast cancer and I had a mastectomy. Finally the insurance companies have been forced to accept that there are situations where a unilateral mammogram is done for screening purposes, and I believe that there is now a billing code for that purpose as well. It’s a shame that our system differentiates between diagnostic procedures for payment, as well as a host of other stupid rules that ignore medical necessity and medical judgment. Right now I’m practicing in New Zealand, where there as still plenty of rules, but at least they apply to everyone, equally and there are ways to advocate to change the system.

  4. 4 Annemarie Donato January 20, 2020 at 10:13 am

    Great example how we continue to have issues with cost of healthcare in the United States.
    Healthcare as well as medications, procedures etc when indicated is something that needs to be available to everyone, not just those who have the money to pay for it or private insurance.
    Annemarie Sipkes Donato, DNP FNP

  5. 5 Peter E Balsam MD January 23, 2020 at 7:16 am

    The rules are insane and backwards; they have been promulgated by bean counters who have no medical training. Don’t worry, it will get worse. But to make it better, the government will train NP and/or PA’s over a weekend to do the procedures. The rules will be more strict but thankfully, the reimbursement will be paltry to save money. Bend over, here it comes again.

    • 6 Penny Placke, PA-C February 2, 2020 at 1:50 am

      I agree with the frustration of insurance and medical costs. Anyone like myself in the field over 20 years has undoubtedly dealt with issues such as this over and over again. It obviously has to do with physician charges, insurance and government rules. Bringing to the table a comment like “teach a PA or NP to do it in a weekend” is not only ridiculous, it doesn’t help the cause, just turns this professional resource into another Facebook.

  6. 7 Kate Miner January 26, 2020 at 3:47 am

    I deal with this every day. I am tired of lying for patients. They can do it as diagnostic or not do it at all. I will not call it screening unless it is. They don’t get free food at supermarket. If they have symptoms then it’s diagnostic, period. I think SOME patients kind of shoot themselves in the foot telling me about some vague symptoms because they want a colonoscopy for no good reason, like their best friend’s father recently had colon cancer. But basically no dice. Diagnostic is diagnostic. They need to know they will have copays/deductibles. Also, you are wrong about the polyp issue. If the intent of procedure was screening then finding a polyp doesn’t change that. I love Obamacare and hope to see it expanded.

  7. 9 Richard Stein January 26, 2020 at 4:37 am

    I take exception to people implying that the problems you outline are due to Obama or his administration. This woman probably has medical coverage owing to the ACA. Think of all the people who now qualify for screening colonoscopies who would not have it without the ACA. There is a new administration in place and it now falls on them to fix the system. Ask yourself if this woman would be better off without Obamacare. As a doctor, you can only recommend the test the patient needs.

      • 11 Richard Stein January 26, 2020 at 4:54 am

        This reflects the fact that commercial insurance companies are for-profit entities and it is unfortunate that the patient must pay high co-pays and premiums. Screening colonoscopies are free only because it is mandated by law. Without the ACA, people would be paying for screening procedures a well. Patients are paying for the insurance companies’ hefty admin costs, advertising, high executive salaries, and corporate dividends. The health care system in the U.S. is broken. In 2007 I moved to NZ where we have universal health care. Having worked for many years in both countries (24 years in the States and13 in NZ), I can tell you that the overall care is superior in NZ, there are no medical bankruptcies, people can change jobs without fear of losing their insurance, and, if they need hospitalisation, there is no charge. Not only that, but I found that the practice of medicine is much more fulfilling here.

    • 12 Gerald Kaplan, MD February 4, 2020 at 9:02 pm

      Well taken and well expressed.

  8. 13 S. Rajender January 26, 2020 at 8:18 am

    I agree with the overall premise of your argument, but take issue with your statement blaming ObamaCare for the mess.

    You appear to be minimizing the benefit of screening colonoscopies. There is ample evidence based on controlled studies that screening colonoscopies reduce colon cancer death anywhere from 53% to 67%. Therefore, making screening colonoscopies free makes all the sense. Complaining that patients undergoing diagnostic testing have to pay for the test while screening colonoscopies are free implies that you either want all colonoscopies to be free or that all colonoscopies should be paid for by the patient. The former is untenable and the latter undesirable. As a result of screening colonoscopies being free of cost to the patient, people are being screened in unprecedented numbers in the last few years, which is a good thing.

    Don’t blame ObamaCare for insurance companies claiming that a screening colonoscopy is no longer a screening colonoscopy and becomes a diagnostic colonoscopy if a polyp is found. This is just a loophole that the greedy insurance companies are using to avoid paying for a screening colonoscopy.

    • 14 acountrydoctorwrites January 26, 2020 at 8:21 am

      Maybe this is one step in the direction of a serious debate about why some kinds of healthcare should be free and others not. Having worked in Sweden I have seen many negative aspects of essentially free healthcare for all but what we’ve got here in the United States is worse in many ways

  9. 15 Mike Kestell MD, January 26, 2020 at 9:24 am

    The problem is not insurance, the problem is your patient feels entitled. She does not fit a screening demographic and is not entitled to a screening benefit. Your job is to educate her, and it is her option to follow your advice. There is no insurance company in the world that will cover a screening exam in a 40 year old. By suggesting you list this as screening she is asking you to commit insurance fraud. Advise her of you recommendation and document her declining your advice. Then consider CT imaging.

  10. 16 Paul Guarino, MD FACG FACP January 27, 2020 at 12:19 pm

    This was NOT due to the ACA/ ObamaCare. This rule was present long before that under CMS. Only Congress is able to stop the unfair practice of billing being changed from ‘screening’ to ‘diagnostic’ if a polyp is removed. It does need to be corrected, to increase access for patients. The ACG, AGA and ASGE are all working to do so.

  11. 17 Stephen Gerrish February 9, 2020 at 8:55 am

    Tell her to lie to the surgeon and claim her mother had colon cancer at age 40 and she has no symptoms. Voila! Screening colonoscopy!! Sometimes you just have to game the system. Btw most commercial insurers are covering as screening even if biopsy or polypectomy is done, as long as proper modifiers are used on billing.
    Medicare generally is not, however.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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