The big Washington dodge on Obamacare's prevention provision

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Preparing for a colonoscopy is half the battle -- at least if you don't have issues with your insurance company.

When politicians, pundits and other know-it-alls tussle over whether to renovate, repeal or preserve Obamacare, they talk about Medicare expansion, the enrollment mandate and the ban on excluding pre-existing conditions. No one complains about one key provision: that insurers pay fully, with no copay or deductible required, for the most effective preventive procedures.

You might think that’s because that requirement is so clear and noncontroversial that no one, not even a flinty-eyed insurance adjuster, could look askance at it. If so, you would be wrong.

Regence BlueShield, the state's and region's largest insurer, doesn’t dispute that provision openly. In fact, Regence doesn’t seem to want to talk about it at all. But where it counts, in the processing of claims from thousands of member-customers, Regence, acting on behalf of the state of Washington, is brazenly defying the ACA’s requirement, amplified by follow-up federal directives, to cover one preventive procedure with proven lifesaving value.

That procedure is colonoscopy, which uses a flexible probe to detect, at a harmless early stage, the polyps that may grow into colon and rectal cancers and remove them on the spot with a hot wire extended from the probe. The U.S. Cancer Society deems it the most “sensitive” – i.e. effective – method for detecting colorectal cancer. The U.S. Preventive Services Task Force, the federal panel charged with evaluating preventive procedures, gives it a top “A” rating. You, too, may know or know of people who met a sad early end because they would not or did not have their innards probed.

Three national gastroenterological societies claim that colonoscopies could prevent half the 50,000-plus deaths from colorectal cancer in the United States each year. A 2007 study published by the National Institutes of Health found that they could prevent 64 percent of all colorectal cancers. If everyone over 50 got scanned on schedule (typically every 10 years), they’d also save our perversely incentivized medical system a ton of cash; the cost of colonoscopies pales before the $250,000-plus tab to treat advanced colorectal cancer.

Still, that cost is a lot higher than the bill for other preventive measures such as immunizations, eye exams, pap smears and daily aspirin. One leading health blog found cash patients paying anywhere from $600 to $5,400 for colonoscopies that take as little as half an hour, depending on provider, region and whether any polyps got snipped in the process. Some gastrointestinal clinics pump up the bill by administering full anaesthesia, which isn’t needed, and charging duplicate facilities charges if polyps are found. I know someone who paid cash for a colonoscopy at a top private hospital in Rio de Janeiro – and paid less than the insurance copay for one in Seattle.

The Affordable Care Act now dangling before the U.S. Supreme Court supposedly eliminated such concerns; it mandates that insurers fully cover colonoscopies along with other approved preventive procedures. But when I called a gastroenterology clinic to schedule a scoping, the payments adviser asked about my insurance – the Uniform Medical Plan for Washington state employees, administered by Regence BlueShield, about as good as insurance gets – and recited a warning she’d clearly given many times before: Regence would cover the whole thing as long as nothing got snipped. But the cost of removing and testing any polyps found, even benign, would be subject to deductible and copayments.

That doesn’t sound right, I said; snipping polyps is an integral part of colonoscopies. (Indeed, it’s done in about a quarter of them.) She agreed, and lamented that Regence and other insurers didn’t see it that way: “Unfortunately, it prevents some people from getting screened. We have new guidelines saying it should be covered, but the insurance companies keep finding ways to get around them. Regence is one of the better plans, actually. Some of the others get really sticky about allowing colonoscopies at all – probably some of the smaller plans that got grandfathered in” when the ACA arrived.

I’m calling Regence about this, I said. “Good luck,” she said.

I called and discovered that Regence’s policy was even stranger than the clinic had said: If even one measly might-be polyp was found, the entire colonoscopy would be deemed a treatment rather than preventive procedure, requiring copay and deductible payments. The Regence rep tried to shift the blame to the clinic: “It just depends how they code the procedure.” But aren’t they required to use certain codes if they snip, and won’t you then charge it as a diagnostic procedure? I didn’t get a straight answer, so I took a metaphysical tack: How can something like a colonoscopy be transformed midway in its course? If it starts out preventive, doesn’t it remain preventive, whatever else it may become? That’s just the way it is, she said.

So I looked for backup. I called the Washington Insurance Commissioner’s Office and reached a helpful health-care compliance analyst named Robert Solano. He said Regence’s policy was particularly dismaying since the U.S. Department of Labor, which which oversees implementation of the ACA, had explicitly declared otherwise in the FAQs about Affordable Care Act Implementation that it issued in February 2013. To wit: Because “polyp removal is an integral part of a colonoscopy … the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure.”

Unfortunately, Solano added, because the Insurance Commissioner’s Office had no authority over self-insured plans such as the state’s, it couldn’t tell Regence what to do. But he offered to send a letter, admittedly toothless, on my behalf. Maybe Regence would back down.

Regence didn’t. Its reply, auto-signed by “Wendie G., Correspondence Ambassador,” is a masterpiece of evasion and obfuscation. It half-concedes that “services designated with an A or B rating by the United States Preventive Services Task Force (USPSTF) may be covered as preventive care.” Emphasis added; note the substitution of “may” for the actual mandatory language.

Wendie G. goes on to blame providers for billing colonoscopies “as medical treatment instead of a preventive service.” Once they do that, the insurer has no choice but to charge a cost-share for it.

I called the gastroenterology clinic back and read that hair-splitting response to Angela, who affirmed that it was indeed horse pucky. We just report what we do, she explained. They decide how to define it.

Solano at the Insurance’s Commissioner’s office suggested I try the feds next, and gave me a number to call at the U.S. Department of Labor. And so I marched into the bureaucratic labyrinth.

A sympathetic claims analyst answered immediately at DOL. She affirmed that “if the primary visit is for colonoscopy, they have to pay for that. If any surgery is involved they can charge cost share for that.” I explained again what Regence contended – that if even one might-be polyp got snipped for testing, the entire colonoscopy became, in effect, surgery. “Oh my gosh, that’s wrong!” she exclaimed. “It’s wrong under the public health services rules and the Affordable Care Act.”

Unfortunately, she explained, DOL couldn’t do anything about it either; thanks to another wrinkle in the law, it had jurisdiction only over private employers. Public-sector workers like me had to go to the U.S. Department of Health and Human Services. “I don’t like to pass the buck, but you have three different entities involved, HHS, IRS, and DOL. HHS doesn’t do much, doesn’t answer the phones, so it may take a week or so for them to get back. The IRS is a little better. A lot of participants will contact us because they don’t hear back from HHS or IRS.”

Don’t feel bad if your head is spinning, she added. “It’s difficult to understand. It’s difficult for us to understand. It’s a confusing piece of legislation.” She also gave me a number to try at try the state Public Employee Benefits Board.

No help there. “There’s not a lot we can do about that,” said the guy who answered at the Benefits Board. “We basically deal with retirees’ health care, COBRA, that sort of thing. But I’ll transfer you to Doug Sample, who’s in charge of active employees.” Doug Sample answered, but interrupted as I started to recite my plaint. “Wait – there are two Doug Samples here. I’ll send you over to the right one.” It must be tough being the wrong Doug Sample and getting the other Doug Sample’s calls, I said. He laughed. “It happens all the time.”

Two Doug Samples? I started expecting John Cleese to appear, walking funny and asking if I had a Form Z4763YH882.

(Later, when I finally reached the right Doug Sample, he apologized and explained that he was also a wrong Doug Sample; he dealt only with payments, not coverage issues. But he offered to try to forward my questions to somebody who could speak to them.)

By now I realized there might be something here worth writing about here, and sought comment from Regence. I left messages for three media reps listed on its website and never heard back from any of them.

I did however hear back from a concerned but apparently overwhelmed claims analyst at U.S. DHHS – sure enough, a week or so after leaving a message. “I haven’t dealt with this issue in several years,” she said after I told my tale yet again. “I heard it many, many times in 2010. But once that Frequently Asked Questions document was issued, it seemed to clear things up" (See this 2011 Crosscut story by Harris Meyer on colonoscopy payment dodges then.)

"This definitely sounds like something that shouldn’t be happening, and we do have jurisdiction. So once I have your information I’ll forward it to the appropriate team.”

That was mid-January. I forwarded all the documents and letters I had but didn’t hear back till March 30. She called, apologized for not following up sooner, took down my account again, and said she’d forward it to her boss. “He’ll confirm whether this is being done [by Regence] and then take steps to rectify the situation.”

By then, however, I didn’t have any skin in the game, or other tissue. I’d performed the obligatory purging, gotten doped out on the gastroenterologist’s gurney, and gotten an all-clear on my innards. No snip, no fault.

But I’m sure thousands – millions? – of others who’ve reached the age of colonoscopy aren’t so lucky. They’re getting reamed twice, the second time when they get their bills and discover how much an ounce of prevention costs when an insurance company decides not to call it prevention.

I suppose it’s no surprise Regence and, doubtless, other insurers (Regence is indeed one of the better ones) take advantage of this de facto loophole in a law that they helped write. In contrast to so many other criticisms of the ACA, however, the issue here isn’t complexity; the prevention provision is pretty straightforward. It’s the creakiness and Balkanization of the governmental systems that are supposed to enforce it.


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About the Authors & Contributors

Eric Scigliano

Eric Scigliano

Eric Scigliano's reporting on social and environmental issues for The Weekly (later Seattle Weekly) won Livingston, Kennedy, American Association for the Advancement of Science, and other honors. He has also written for Harper's, New Scientist, and many other publications. One of his books, Michelangelo's Mountain, was a finalist for the Washington Book Award. His other books include Puget SoundLove, War, and Circuses (aka Seeing the Elephant); and, with Curtis E. Ebbesmeyer, Flotsametrics.