Providers Praise HHS’ Colonoscopy Shift But Want Policy Extended To Medicare

Gastroenterology and cancer groups praise HHS for clarifying that the health reform law’s preventive services cost-sharing exemption applies to certain preventive colonoscopy procedures, but the stakeholders are upset the clarification covers only private plans and will urge Congress to extend the policy shift to Medicare.

HHS specifically closed a “loophole” in the health law’s provision that eliminated cost-sharing for preventive services by clarifying that a patient receiving a screening colonoscopy is also exempt from cost-sharing if the provider finds and removes a polyp during the procedure. Stakeholders have long urged HHS to make that clarification, which the department finally included in a Frequently Asked Questions (FAQ) document posted last week. However, stakeholders note that the clarification is only for private plans, not Medicare, and support additional legislation that would clear up the policy in the federal program, and providers also seek reimbursement for pre-operative talks with patients.

Stephen Finan, senior policy director for the American Cancer Society Cancer Action Network (ACS CAN), says that the “loophole” had led insurers to reclassifying the procedure as a diagnostic service, rather than a preventive service, if a polyp was removed. “This loophole meant patients could find themselves with an unexpected cost burden for a preventive service that was supposed to be free, as it carried an “A” rating by the United States Preventive Services Task Force,” Finan said.

American College of Gastroenterology’s (ACG) National Affairs Committee Chair March Seabrook tells Inside Health Policy he is pleased that HHS has corrected the glitch — an issue that GI doctors have been working on for years. It did not sense that if a doctor finds a polyp that the patient could end up with a larger bill, he said.

“If we were smart enough to know a patient had no polyps, there’d be little need for the procedure,” Seabrook says. Polyps are found and removed in about 25 percent of men and 15 percent of women who undergo a screening colonoscopy, Seabrook says, noting that most figures are “low-end” estimates.

Seabrook also says his group still supports legislation offered by Rep. Richard Neal (D-MA) that would have fixed the loophole as it also would allow patients to have a pre-operative visit with a gastroenterologist. Such a visit would give patients and doctors a chance to talk about issues prior to the procedure, and could prevent patients from getting unnecessary invasive testing.