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Medicine :: Getting Insurance To Pay For Preventive Health Under The Aca
1. Medicine :: 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
2. 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.
The question is how do consumers inform the government of the need for a special coding or
otherwise provide guidance on preventive screening based on intent at time of service, not on
subsequent findings? I could write my local congressman, but he is a newly elected conservative
Republican who opposes health care and everything else proposed by Obama. If I wrote him on the
need for clarification of preventive health visits, he would interpret that as a letter advising him to
vote against health care reform at every opportunity. I doubt my two conservative Republican
senators would be any different. They have stand pat reply letters on health care reform that they
send to all constituents who write in regarding health care matters.
To my knowledge, there is no way to make effective suggestions to the Obama administration.
Perhaps the only solution is to publicize the problem in articles and raise these issues in discussion
forums
There is a clear and absolute need for government to get involved in the health care sector. You
seem to forget how upset people were with the non-government, pure private sector-based health
care system that left 49 million Americans uninsured. When those facts are mentioned to people
abroad, they think of America as having a Third World type health care system. Few Japanese,
Canadians, or Europeans would trade their existing health care coverage for what they perceive as
the gross inequities in the US Health Care System.
The Affordable Care Act, I agree, completely fails to address the fundamental cost driver of health
care. For example, it perpetuates and even exacerbates the tendency of consumers to purchase
health services without any regard to price. Efficiency in private markets requires cost-conscious
consumers; we don't have that in health care.
I am glad the ACA was passed. It is a step in the right direction. As noted, there are problems with
3. the ACA including the "preventive health visits" to the doctor, which are supposed to be covered
100% by insurance but may not be if any diagnostic code is entered on the claim form.
Congress is so polarized on health care that the only way to get changes is with a groundswell of
popular support. I don't think a letter writing campaign is the correct way to reform payment for the
"preventive health visits." If enough consumers advise their doctors that this particular visit is to be
treated solely as a preventive health visit, and thyroid and cold hands they will not pay for any
service in the event the doctor's office miscodes the visit with anything else, then the medical
establishment will take notice and use its lobbying arm to make Congress aware of the problem.
COMMENT: Should there not be an agreement up front between both parties on what actions that
will be taken if said item is found or said event should be seen or occur? Should their be a box on the
pre-surgical form giving the patient the right to denying the doctor to take proper action (deemed by
whom?) if they see a need to? Checking this box would save the patient the cost of the procedure,
and give them time for a consult. If there is not a box to check, why isn't there one?
There are two separate questions posed by the checkbox election for procedures. First, does a
patient have a legal right to check such a box or instruct a physician/surgeon orally or in writing that
he does not give consent for that procedure to be performed? The answer to that question is yes.
The second question is does it serve the economic interest of the patient to check that box? For the
colonoscopy, in theory the patient would get his or her free preventive screening, but then be told
the patient needs to schedule a second colonoscopy for removal of a suspicious polyp. In that case,
the patient would eventually have to pay for a colonoscopy out of pocket (unless he had already met
his yearly deductible), so there is no clear economic rationale for denying the physician the right to
remove the polyp during the screening colonoscopy.
But we are using the much less common colonoscopy example. Instead, let's return to preventive
care with a primary care doctor. Should a patient have the right to check a box and say "I want this
visit to cover routine preventive care and nothing more"? Certainly. There is way too much
discretion afforded physicians to code up whatever they want on claim forms such that two
physicians seeing the exact same patient might code up different procedures and diagnostics for the
exact same preventive health screening visit.
When I expect to receive a "zero cost to me" preventive screening, I do not imply that I am willing to
accept a "bait and switch" change of procedure and payment due to the doctor from me. The "zero
cost to me" induces consumers to go to the office visit; it is actually paid for out of the profits earned
by the health insurance firms to whom consumers pay monthly premiums. Consumers need to hold
doctors financially accountable for their claim billing practices. If you are quoted a "zero price" for a
visit, the doctor's office better honor that price, or it amounts to fraud.
It is all too easy to find any little old thing to justify billing a patient for a sick visit instead of a
wellness visit. However, it is up to the patient to prevent that kind of profiteering at his or her
expense.
It would be wonderful if HHS would give carriers the proper code or specify that other diagnostic
codes cannot negate the preventive screening code used for a wellness visit. That is not happening
now. DHS has been bombarded with so many questions and suggestions for health care reform that
the department has a fortress like mentality. So realistically, consumers cannot expect DHS to
4. address the coding issue for preventive health screenings any time soon. That leaves the full burden
to fall on each consumer to ensure the doctor's billing practices match the patient's expectations for
a free preventive health office visit.
I investigated the web site
http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html and discovered
some inconsistencies. For example, the site purports to list the services covered under the
"preventive health" coverage benefit, yet it omits the annual physical exam. Also, the site states that
colorectal cancer screening are provided for people age 50 or older. However, I have been advised
in writing that United Healthcare will cover preventive screening colonoscopies for people under
age 50. In essence, that government web page is a good start to learn about preventive health care
benefits, but a better source would be each consumer's own health insurance carrier. For those with
temporary insurance or who are without any insurance coverage, unfortunately, the preventive
health benefit of the ACA will not have any practical consequence.
Where will the money come from for the preventive health screening visit to a primary care doctor
as well as the screening colonoscopy? We have to look at different scenarios. If the patient indeed
has preventive health screenings with no other medical diagnoses, then the patient will be charged
$0 for these services, and they will be paid for by the insurance carrier. The insurance carrier will
pay these costs out of its operating income or profits. There is simply no other source for payment.
The government has not offered to pay the insurance companies for these services.
If the patient is hit with various medical diagnostic codes during these preventive health screenings,
then he or she will pay his customary charge for the primary care doctor's office visit and the
contract-negotiated price for the diagnostic colonoscopy. In that scenario, the consumer will be
paying most of these costs, although the visit to the primary doc may be limited up to any applicable
copay amount.
It is not a big shock or surprise to say preventive health care is going to be borne by health
insurance carriers. The extent to which these carriers can pass along costs to consumers through
higher rates depends on the degree of competition in their markets. Ehealthinsurance.com advises
5. me that for the vast majority of states, the insurance carriers have NOT been able to shift these
costs onto consumers through higher rates. That may change in 2013 or 2014. However, the trend is
clearly moving in the direction of more power for consumers, more options and carriers available to
supply health insurance in their states, which means greater competition and lower prices.
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