As colorectal cancer cases rise, gastroenterologists are pushing for patients to receive screenings, but some colonoscopy insurance loopholes stand in the way.
Here are two colonoscopy payment "loopholes" that gastroenterologists are eyeing:
1. Some patients pay out of pocket for colonoscopy prep, according to a recent study, and many leaders are concerned about how that could affect screening volumes. The study found that only 17% of patients pay nothing for their bowel preparation for screening colonoscopy and that almost half of patients are directed toward using non-FDA-approved over-the-counter regimens.
Study leader Eric Shah, MD, a gastroenterologist at Ann Arbor-based University of Michigan, told Becker's the research identified a loophole where prescription drugs are tied to screening costs, and Medicare patients end up paying more.
Only 36% of the prescription claims analyzed had no out-of-pocket costs. For Medicare Part D, only 25% of high-volume preps were free. This loophole presents an added barrier to getting patients screened for colon cancer.
"If patients have to pay out of pocket for the prep, it could lead them to delay screening, especially given the current economy," Dr. Shah said. "If someone puts off screening because of $19, that’s a real problem. We need to reduce those barriers."
Dr. Shah noted that a major issue with getting patients screened is that bowel prep becomes a significant barrier, particularly with high-volume options. For many low-volume prep options, insurance barriers still prevent coverage. But for many low-volume prep options, insurance barriers wind up preventing patients from being covered. And while some drug companies offer a copay card to lower the cost, it still can be expensive, he said.
2. Another "loophole" in colonoscopy reimbursements is the fact that if a colonoscopy becomes diagnostic, patients can expect to pay 15% of the Medicare-approved amount for a physicians' services. In ASCs, patients may also pay a 15% coinsurance amount.
Some states are making efforts to change that policy.
On Aug. 9, Illinois Governor J.B. Pritzker signed into law a bill which requires insurance coverage for all colonoscopies in patients that show signs or symptoms of colon cancer or have an existing colon condition. The law effectively grants free access to all medically necessary colonoscopies in the state.
Current legislation requires insurance to cover colonoscopies as a follow-up exam after receiving a recommendation from a primary care physician, but the new legislation will eliminate the follow-exam requirement.
In April, Nebraska Gov. Jim Pillen signed a bill prohibiting insurance policies from imposing a deductible co-insurance or cost-sharing requirement for removing polyps or for biopsies associated with a screening for colorectal cancer for people 45 and older. The proposal will start Jan. 1, 2025.
"If you look at the language for the ACA, the intent was that people would be able to get their colonoscopy, and if something was discovered, that it would also be removed during that procedure," Nebraska Sen. Carol Blood told 6 News in January. "But the language has a loophole in it. So what Nebraskans would find is that during a colonoscopy, if something was discovered, such as a polyp, and it was removed, that their insurance was not paying for it."