Free preventive visit can end in sticker shock for patients

Staff members at the practice of Lawrence Kosinski, MD, a gastroenterologist in Chicago, call patients three times before a screening colonoscopy appointment to discuss various aspects of the procedure, including any potential bills for removing polyps found during the test.

Still, sometimes patients are bewildered by invoices received for what they believe is a completely paid-for preventive visit -- but turns out to require out-of-pocket payment because a problem was detected.

Patients "get very upset -- no matter how pleased they are with the procedure -- if they receive a surprise bill," said Dr. Kosinski, a spokesman for the American Gastroenterological Assn.

To encourage preventive visits, the Patient Protection and Affordable Care Act requires most health insurance plans, including Medicare, to cover such services fully without cost-sharing. Physicians say the well-intentioned rule is not without complications, however. Free preventive care could result in a diagnosis or follow-up treatment, which is not free.

Physicians and experts recommend that doctors be as clear as possible when explaining to patients what is covered fully as a preventive visit and procedure -- and what is not. They say that is best done before the preventive visit, so there are no surprises. Physicians should be clear that no matter what else ends up becoming the patient's responsibility to pay, the preventive services will be fully covered.

"I still believe communication is key here," Dr. Kosinski said. "We need to provide patients with as much assistance as we can."

Medical societies are advocating changes that would make it more likely for patients to get recommended preventive services without creating more confusion and surprise over billing. In response to the interim rule for the preventive services coverage portion of the health reform law, the American Medical Association submitted comments, dated Sept. 17, 2010, advocating that co-pays and deductibles be waived for any visit involving prevention regardless of whether diagnosis and treatment were provided during the same visit.

Meanwhile, the gastroenterology specialty societies support a bill in the House Ways and Means Committee that would waive coinsurance if colorectal cancer screening turns into a therapeutic procedure.

For now, physicians and patients are trying to work through what to do when a visit that is free to the patient becomes a paid visit.

34 preventive services covered

There are currently 34 preventive services, broken down by age group and gender, that insurers pay physicians to perform but for which the cost is not passed on to patients. These services include many vaccines; diet, tobacco and alcohol counseling; mammography; diabetes screening; colonoscopies; Pap smears; and cholesterol screening.

Primary care physicians say what often causes billing confusion for patients is a common result of screening: finding something that needs further attention.

Exacerbating the situation, they say, are patients who have long deferred screening procedures because of cost but who undergo the tests because they are now free. Meanwhile, other patients are holding back from screening because of fears about the cost of care if a problem is found.

Consumer media reports have reflected anger from patients who received a colonoscopy. The test was supposed to be free to them, but they were upset when a bill arrived for polyps snipped during the procedure -- which is not free. About 24% of screening colonoscopies lead to the detection and removal of at least one precancerous polyp, says a 2005 study in The American Journal of Medicine.

Blood tests for cholesterol may cause financial confusion. These may be covered fully as a screening test for a lipid disorder but require payment if it is used to monitor treatment. A screening mammogram is covered fully for women over 40, but subsequent testing to assess any potential problems is not.

Difficulty also comes from the need for practices to decide how to handle coding and billing if an acute issue subject to co-pays and deductibles comes up during a wellness visit. "It's very common when patients come in for a preventive exam to have something else they bring to your attention during the review of systems," said Joshua J. Fenton, MD, MPH, assistant professor of family and community medicine at the University of California, Davis. "We cannot tell patients to shut up when they are telling us important clinical information."

Medicare form a model

Most experts say communication about potential bills -- even if it does not entirely solve the problem -- is crucial. The average patient usually does not have a good handle on the differences among screening, diagnosis and treatment.

In addition to verbal communication, experts suggest that practices consider various written handouts and forms. Some practice management consultants recommend Medicare's Advance Beneficiary Notice of Noncoverage form. This may be required for some Medicare patients and can act as a model for a form to be given to privately insured patients. Primary care physicians suggest urging patients to ask specialists who actually perform the procedure about cost.

Practices need to decide what situations trigger a bill for a co-pay or deductible related to diagnosis and treatment, and what keeps the visit firmly in the realm of prevention. For example, many physicians say that if the acute issue that comes up during a preventive visit is very minor, they do not bill for it.

"Doctors and patients really are struggling to make the best out of a system that doesn't always make sense," said Glen Stream, MD, president of the American Academy of Family Physicians. "It really does need to get fixed. ... It impacts people's willingness to get screened, because they are worried about a bill that they didn't expect."