One of the 10 Essential Health Benefits covered under the ACA includes preventative and wellness services, which are provided free, without any cost-sharing such as copays and deductibles. So what preventative services are covered? The ACA requires any service with an “A” or “B” recommendation from the United States Preventative Services Task Force to be offered in a Marketplace health plan, such as diabetes screening and cholesterol testing. But it’s the colonoscopy that is the most exciting “covered” service, one that normally costs from $1,000 to $2,500. Though the procedure itself can be rather daunting, it can save your life.
Yet there are certain situations in which you may be charged for cost-sharing when undergoing a colonoscopy, and it’s generating more complaints that any other of ACA’s preventative services. According to a study by Kaiser Family Foundation, it all comes down to bill coding practices, which identify the service provided. About half of all colonoscopies result in polyp removal (These polyps are a possible precancerous condition and their removal prevents colorectal cancer.) When polyp removal occurs, some providers code the procedure without using the “CPT modifier 33,” which would class it as “preventative,” and thus free from cost-sharing. Nonetheless, most insurers will not charge any cost-sharing for polyp removal, and when it does happen, it is usually a bill coding oversight. Bottomline: When undergoing a screening colonoscopy, Inquire with your provider directly to make sure they use the proper coding to class it as “preventative.”