Patient Cost Sharing for Screening Colonoscopy

AGA Urges Correction of Medicare Beneficiary Cost Sharing for Screening Colonoscopy

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Passage of the Patient Protection and Affordable Care Act marked a major victory in the fight against cancer. The law waives the coinsurance and deductible for many cancer screening tests,1 including colonoscopy, sigmoidoscopy and fecal occult blood testing (FOBT), which screen for colorectal cancer. However, due to the unique nature of colonoscopy, many patients wind up paying out of pocket.

Recently, the Obama administration issued a set of FAQs on the implementation of preventive benefits to the PPACA that clarified that private insurers cannot impose cost sharing for a screening colonoscopy that turns therapeutic since polyp removal is “an integral part of a colonoscopy.” Read more. The AGA applauds the administration for this guidance and will continue to advocate for this policy change in Medicare.  

However, AGA urges Congress to correct this “cost sharing” problem for Medicare patients. H.R. 1070, the Removing Barriers to Colorectal Cancer Screening Act, legislation introduced by Rep. Charlie Dent, R-PA, would correct this cost sharing problem for Medicare patients by waiving the coinsurance for a screening colonoscopy regardless of the outcome. AGA supports H.R. 1070 and urges its passage. 

The Colonoscopy Loophole

Colonoscopy is a unique screening test because gastroenterologists are able to remove precancerous polyps and small cancers during the screening procedure. Under Medicare coding rules, removal of any polyp reclassifies the screening as a therapeutic procedure for which patients must pay coinsurance. This means a patient can go to the gastroenterologist for a colonoscopy assuming it’s free, only to receive a bill for the coinsurance after the doctor finds and removes a suspicious polyp.

Patient Impact

Cost sharing creates financial barriers, which discourage the use of recommended preventive services. This could have a major impact on colorectal cancer screening since almost 38 percent of U.S. adults age 50 and older have never been screened.

2011 Medicare Physician Fee Schedule

CMS stated in the 2011 Medicare physician fee schedule final rule that legislative action is necessary to waive the beneficiary coinsurance for colorectal cancer screenings that become therapeutic during the same clinical encounter. CBO estimates this will cost $200 million over 10 years.

Bottomline: Screening colonoscopy is the most cost effective test for prevention of colorectal cancer. Patients should be incentivized, through the elimination of cost sharing, to use colonoscopy as a colorectal cancer screening mechanism.

Colonoscopy Effective January 2011
Screening
Coinsurance Waived
Deductable Waived
Screening that becomes therapeutic
Coinsurance

Applies

20% of the Medicare-approved amount with no Part B deductible. If the test is done in a hospital outpatient department or surgical center, 25% of the Medicare-approved amount.

Deductible Waived

1. Sec. 4104 of the “Patient Protection and Affordable Care Act” (ACA) waives the beneficiary coinsurance and deductible for covered preventive services that have a grade “A” or “B” from the U.S. Preventive Services Task Force (USPSTF). Colonoscopy, sigmoidoscopy and fecal occult blood testing (FOBT) have all been assigned an “A” rating from the USPSTF for adults beginning at age 50 and continuing until age 75.

Sec. 4104 also requires, effective Jan. 1, 2011, the deductible for colorectal cancer screenings be waived for Medicare beneficiaries regardless of the code that is billed for the establishment of a diagnosis as a result of the test, or for the removal of tissue or other matter or other procedure that is furnished in connection with, as a result of, and in the same clinical encounter as a screening test.


March 2013