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Getting Insurance To Pay For Preventive Health Under The ACA

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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. 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 suppose a patient mentions casually that they are feeling generally tired. In that case, 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 other medical conditions. 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 very 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 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 threat – to get checked. But if people go into the procedure expecting insurance to pay the cost. Then a week later, they receive a surprise letter indicating they are responsible for the $2,000 – $2,500 fee; it will give people a solid financial disincentive to getting tested.

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As an attorney, I wonder how the law could get twisted around to this extent. The purpose of a colonoscopy is determined when an appointment is made, no ex-post-facto during or after the colonoscopy. Suppose 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. In that case, that purpose or intent cannot be negated by subsequent findings of any condition. What if the doctor finds a minor noncancerous infection and notes that on the claim form?

Will that diagnosis void the 100% payment for preventive service? If so, it gives patients a solid 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. Usually, we would want to encourage doctors to share all information with patients, and the patients would like that as well. But securing payment for preventive services requires the doctor to code up the entire procedure as the routine preventive screening.

The question is, how do consumers inform the government of the need for special coding or otherwise provide guidance on preventive screening based on intent at the 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 practical 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 the 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. I agree that the Affordable Care Act 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.

Susan M. Davis

Tv expert. Proud web nerd. Friend of animals everywhere. Hipster-friendly coffee trailblazer. Spent college summers short selling clip-on ties in Hanford, CA. Spent two years developing jack-in-the-boxes for fun and profit. At the moment I'm merchandising human growth hormone in Prescott, AZ. Spent several years implementing birdhouses for the underprivileged. Had some great experience lecturing about spit-takes worldwide. What gets me going now is building chess sets in the aftermarket.

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