Getting Insurance To Pay For Preventive Health Under The ACA

The Affordable Care Act (ACA) mandates that health insurance companies pay for preventive health visits. However, that term is somewhat deceptive, as consumers may feel they can visit the doctor for just a general checkup, talk about anything, and the visit will be paid 100% with no copay. In fact, some, and perhaps most, health insurance companies only cover the A and B recommendations of the U.S. Preventive Services Task Force. These recommendations cover such topics as providing counseling on smoking cessation, alcohol abuse, obesity, and tests for blood pressure, cholesterol, and diabetes (for at risk patients), and some cancer screening physical exams. BUT if a patient mentions casually that he or she is feeling generally fatigued, the doctor could write down a diagnosis related to that fatigue and effectively transform the “wellness visit” into a “sick visit.” The same is true if the patient mentions occasional sleeplessness, upset stomach, stress, headaches, or any other medical condition. In order to get the “free preventive health” visit paid for 100%, the visit needs to be confined to a very narrow group of topics that most people will find vert constrained.

Similarly, the ACA calls for insurance companies to pay for preventive colonoscopy screenings for colon cancer. However, once again there is a catch. If the doctor finds any kind of problem during the colonoscopy and writes down a diagnosis code other than “routine preventive health screening,” the insurance company may not, and probably will not, pay for the colonoscopy directly. Instead, the costs would be applied to the annual deductible, which means most patients would get stuck paying for the cost of the screening.

This latter possibility frustrates the intention of the ACA. The law was written to encourage everyone – those at risk as well as those facing no known risk – to get checked. But if people go into the procedure expecting insurance to pay the cost, and then a week later receive a surprise letter indicating they are responsible for the $2,000 – $2,500 cost, it will give people a strong financial disincentive to getting tested.

As an attorney, I wonder how the law could get twisted around to this extent. The purpose of a colonoscopy is determined at the moment an appointment is made, not ex post facto during or after the colonoscopy. If the patient has no symptoms and is simply getting a colonoscopy to screen for colon cancer because the patient has reached age 45 or 50 or 55, then that purpose or intent cannot be negated by subsequent findings of any condition. What if the doctor finds a minor noncancerous infection and notes that on the claim form? Will that diagnosis void the 100% payment for preventive service? If so, it gives patients a strong incentive to tell their GI doctors that they are only to note on the claim form “yes or no” in response to colon cancer and nothing else. Normally, we would want to encourage doctors to share all information with patients, and the patients would want that as well. But securing payment for preventive services requires the doctor code up the entire procedure as routine preventive screening.
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