AILSA CHANG, HOST:
Studies show that getting a colonoscopy saves lives by detecting or even preventing colon cancer. That's why the Affordable Care Act requires that insurers don't charge a co-pay - because a colonoscopy is one of the preventative services recommended for every adult. But Dr. Elisabeth Rosenthal from our partner Kaiser Health News is here today, and that usually means something is not going as it should in our health care system, right?
ELISABETH ROSENTHAL: Unfortunately, that's right. I'm here with another Bill of the Month.
CHANG: Exactly. Well, I just got my first colonoscopy, so I am very interested in what we are going to be talking about today. Who are we meeting here, and how did things go sideways for this person?
ROSENTHAL: Well, first, congratulations to you.
CHANG: Thank you.
ROSENTHAL: Today we're meeting Elizabeth Melville of Sunapee, N.H. She got a big bill after a colonoscopy.
CHANG: Oh, OK. And reporter Stephanie O'Neill has her story. Let's take a listen.
STEPHANIE O'NEILL, BYLINE: For Elizabeth Melville of New Hampshire, staying healthy is a way of life. The 59-year-old is a ski instructor and avid hiker who hopes to stay active for all her remaining decades. And that's why last September, she wasn't about to miss her scheduled colonoscopy, the preventive health screening recommended for most people every 10 years starting at age 45.
ELIZABETH MELVILLE: The procedure all went very well. The doctor came in, and he did mention that they had found a small polyp that they'd removed.
O'NEILL: A similar thing happened during Melville's first colonoscopy in 2015. Everything turned up normal except for a benign polyp her doctor excised during the screening. Removing these common growths during screenings is standard operating procedure because they can develop into malignant cancers. And it's recommended those with a history of them, like Melville, undergo colonoscopies more frequently - every five years.
MELVILLE: And then five years ended up being during COVID.
O'NEILL: So she had to wait a bit longer. And during that time, she had moved from Connecticut, where she continues to get most of her medical care.
MELVILLE: But something like a colonoscopy - that procedure - not something I wanted to travel with.
O'NEILL: So Melville visited a new doctor near her home in New Hampshire, and she expected the procedure to cost her nothing. That's because under the Affordable Care Act, colonoscopy screenings are zero-cost procedures, meaning patients pay nothing out-of-pocket. And that's what happened with her first screening.
MELVILLE: There was no bill. Insurance covered at all, so I just assumed the second one would be the same way.
O'NEILL: But her provider apparently missed that memo, and instead, it billed her insurer more than $10,000. The insurance company negotiated the bill down by more than half, but that still left Melville on the hook for about 2,100 bucks. She asked her insurance why she had to pay anything at all.
MELVILLE: And they said, well, it was initially submitted as screening, and then they resubmitted the bill as diagnostic. And I thought, well, they must have made a mistake. They've confused me with another patient.
O'NEILL: But they didn't. Under the federal health law, while a provider can't bill patients for a colon screening, they can bill for a diagnostic treatment. But using a polyp discovered during a colonoscopy as the trigger to shift the cost onto the patient - that didn't sit well with Elizabeth Melville.
MELVILLE: The whole reason you have a screening colonoscopy is to prevent colon cancer. People that can't afford it - will it stop them from having a colonoscopy to begin with?
O'NEILL: Since colonoscopy screenings became free to patients nearly 10 years ago, the government has repeatedly informed providers that polyp removal during a screening colonoscopy should not wind up costing patients anything at all. For NPR News, I'm Stephanie O'Neill.
CHANG: OK. We're back now with Dr. Elisabeth Rosenthal. And, Dr. Rosenthal, I remember this was part of the discussion around the Affordable Care Act when it first came out. So let me ask you, if a colonoscopy does find something, can you be charged for it?
ROSENTHAL: Well, according to the government's interpretation of the ACA, there should not be a cost to you even if they do find a polyp. And it has reiterated that point several times. I mean, as Miss Melville says, the whole point of screening is to see if there's a potentially problematic growth and snip it out for testing to make sure it doesn't evolve into a cancer.
CHANG: Exactly. So why is the patient being charged here?
ROSENTHAL: Well, some providers continue to regard it as a kind of gray area. And, hey; if the patient doesn't know to protest, the provider gets paid for the charge.
CHANG: Well, I mean, are there times when you could be legitimately charged after a colonoscopy?
ROSENTHAL: In some cases. If you're having symptoms, your doctor may order a diagnostic colonoscopy. Yeah, you can be charged for that. Or if you're at very high risk, the test could be called diagnostic from the beginning. But it's not OK to change the game in the middle of the test like, oops, suddenly you owe 2,000.
CHANG: Right. So how often do people get bills like Elizabeth did here?
ROSENTHAL: Well, part of the reason we chose to do this one is we do get a number of complaints about colonoscopy charges to Bill of the Month. The problem is that there are three categories of colonoscopy - screening, diagnostic, even treatment. And where your colonoscopy falls can be a bit in the eye of the beholder.
CHANG: Beholder - and beholder in this case is the one who sends you the bill.
ROSENTHAL: Yes. And if you're thinking revenue, that may not sound very noble, but it doesn't hurt to try and bill. We do know the government hasn't been doing any enforcement of the rule with hospitals or insurers. So, you know, that kind of leaves the door open.
CHANG: OK. Well, what eventually happened to our patient, Elizabeth Melville?
ROSENTHAL: Well, as so often happens after a reporter called, the story changed. And the hospital said, oh, sorry, it was a mistake.
ROSENTHAL: So good news - she doesn't owe the $2,000.
CHANG: All right. That is a great result for her. So for everyone who does get a colonoscopy, what should they keep in mind in general? I'm going to think about this in 10 years (laughter).
ROSENTHAL: Yeah. I mean, we cannot do a Bill of the Month for every colonoscopy in America. So the screening should be at no cost to patients. So ask the practice before you do the dreaded prep for assurance that the test will be billed as screening even if a polyp is found and biopsied or removed. Ask to see those consent forms before you've done your clean-out, and don't sign one in which you agree to pay for anything your insurance doesn't cover. People between the ages of 45 and 75 who have no symptoms should be able to get their regular recommended screening colonoscopies for free.
CHANG: Great advice. And to everybody who has a colonoscopy coming up, good luck. Dr. Elisabeth Rosenthal, editor-in-chief of Kaiser Health News, thank you so much for being with us again today.
ROSENTHAL: Thanks for having me. I have one coming up, too.
CHANG: Oh, good luck to you. And if you have a bill you think is not quite right, please go to NPR's Shots blog and send it to us. We'd love to hear about it.
(SOUNDBITE OF THE PHARCYDE SONG, "SHE SAID")
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