Preventive-care coverage confuses

Associated Press

CHICAGO

Bill Dunphy thought his colonoscopy would be free.

His insurance company told him it would be covered 100 percent, with no co-payment from him and no charge against his deductible. The nation’s 1-year-old health law requires most insurance plans to cover all costs for preventive care including colon-cancer screening. So Dunphy had the procedure in April.

Then the bill arrived: $1,100.

Dunphy, a 61-year-old Phoenix small-business owner, angrily paid it out of his own pocket because of what some prevention advocates call a loophole. His doctor removed two noncancerous polyps during the colonoscopy. So while Dunphy was sedated, his preventive screening turned into a diagnostic procedure. That allowed his insurance company to bill him.

Like many Americans, Dunphy has a high- deductible insurance plan. He hadn’t spent his deductible yet. So, on top of his $400 monthly premium, he had to pay the bill.

“That’s bait and switch,” Dunphy said. “If it isn’t fraud, it’s immoral.”

President Barack Obama’s health overhaul encourages prevention by requiring most insurance plans to pay for preventive care. On the plus side, more than 22 million Medicare patients and many more Americans with private insurance have received one or more free covered preventive services this year. From cancer screenings to flu shots, many services no longer cost patients money.

But there are confusing exceptions. As Dunphy found out, colonoscopies can go from free to pricey while the patient is under anesthesia.

Breast-cancer screenings can cause confusion too. In Florida, Tampa Bay-area small-business owner Dawn Thomas, 50, went for a screening mammogram. But she was told by hospital staff that her mammogram would be a diagnostic test — not preventive screening — because a previous mammogram had found something suspicious. (It turned out to be nothing.)

Knowing that would cost her $700, and knowing her doctor had ordered a screening mammogram, Thomas stood her ground.

“Either I get a screening today or I’m putting my clothes back on and I’m leaving,” she remembers telling the hospital staff. It worked. Her mammogram was counted as preventive and she got it for free.

Should insurance now pay for aspirin? Aspirin to prevent heart disease and stroke is one of the covered services for older patients. But it’s unclear whether insurers are supposed to pay only for doctors to tell older patients about aspirin — or whether they’re supposed to pay for the aspirin itself, said Dr. Jason Spangler, chief medical officer for the nonpartisan Partnership for Prevention.

Stop-smoking interventions also are supposed to be free. “But what does that mean?” Spangler asked. “Does it mean counseling? Nicotine replacement therapy? What about drugs [that can help smokers quit] like Wellbutrin or Chantix? That hasn’t been clearly laid out.”

But the greatest source of confusion is colonoscopies, a test for the nation’s second- leading cancer killer. Doctors use a thin, flexible tube to scan the colon, and they can remove precancerous growths called polyps at the same time. The test gets credit for lowering colorectal-cancer rates. It’s one of several colon-cancer screening methods highly recommended for adults age 50 to 75.

But when a doctor screens and treats at the same time, the patient could get a surprise bill.

Cindy Holtzman, an insurance agent in Marietta, Ga., is telling clients to check with their insurance plans before a colonoscopy so they know what to expect.