Think Obamacare will cover your next colonoscopy? Think again.

As the program director of a large colon cancer-screening program, we often find uninsured patients waiting for Obamacare to go into effect before they schedule their colonoscopies. Patients’ state they have heard colonoscopies will be covered 100% under the new law. This prompted us to look into the extent of coverage that will be provided. Could all colonoscopies be covered at 100%? Could our prayers have been answered?

Unfortunately, they weren’t.

Below is the exact statement issued by the government:

“Based on clinical practice and comments received from the American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and the Society for Gastroenterology Nurses and Associates, polyp removal is an integral part of a colonoscopy. Accordingly, the plan or issuer may not impose cost sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure. On the other hand, a plan or issuer may impose cost-sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.”

In 2014, insurance providers will be forced to (1) cover a screening colonoscopy at 100% and (2) classify the colonoscopy as screening even if polyps are found.

It was news welcomed by the gastroenterology community and cancer advocates. However, what this statement does not do is define what is considered screening and leaves insurers flexibility on how to define a procedure as screening or diagnostic.

This lack of clarity has big implications. If you have a high deductible insurance plan and your procedure is not considered a screening, you could be responsible for thousands of dollars in medical bills.

Below is a list of potential scenarios where your colonoscopy will not be considered a screening and will result in your procedure not being fully covered:

1)     You are not completely asymptomatic:
Common symptoms such as diarrhea, constipation, and blood in your stool or pain will disqualify you from a 100% covered colonoscopy as your procedure is now considered a diagnostic procedure.

2)     A past colonoscopy resulted in an IBD diagnosis:
If you were diagnosed with ulcerative colitis or any form of inflammatory bowel disease (IBD), insurance providers may consider your future colonoscopies as diagnostic and not preventative. 

3)     Your physician recommended procedures at intervals sooner than every 10 years:
If your past colonoscopy resulted polyps being found, your physician may have asked you to have your follow up colonoscopy in 5 years instead of 10. Insurers differ in opinion on whether the follow up colonoscopy is considered as screening. If the follow up colonoscopy is not considered screening, you will be responsible for cost sharing.

4)     You need a colonoscopy due to a positive FOBT test:
It is still unclear if all insurance providers will consider your colonoscopy as a screening if you are referred for a colonoscopy due to a positive FOBT test. If they consider the colonoscopy as diagnostic you will be responsible for cost sharing.

5)     Your physician does not bill your colonoscopy accurately:
With an increasingly complex health care billing system, the exact same colonoscopy procedure can be billed in a number of different ways. If your colonoscopy is not billed as a screening you may be in for an unexpected surprise. Unfortunately, the average consumer is not well versed in medical billing terminology to recognize and correct billing errors. 

6)     Anesthesia and pathology charges:
While charges for your colonoscopy are covered if your procedure is considered screening it still is not completely understood how insurance providers will handle anesthesia and pathology charges. For example: Insurance providers may consider MAC anesthesia an added comfort and therefore subject to cost sharing. They may consider pathology from biopsies taken to determine the extent of ulcerative colitis as diagnostic even though the procedure was considered a screening.

While the new legislation is a step in the right direction, individuals should not be under the impression that all colonoscopies will be fully covered once Obamacare goes into effect in 2014. Especially consumers with a high deductible plan as they might find themselves with thousands of dollars in unexpected bills.

We're happy to answer any questions you may have about the effect Obamacare will have on colonoscopies. Please feel free to contact us at info@colonoscopyassist.com or visit our website for more information: http://www.colonoscopyassist.com

Ali Poonawala is the Program Director at the Colonoscopy Assist Program. The program assists uninsured and underinsured patients with colonoscopies.