Building on the efficacy of colorectal cancer screening, the American Medical Association endorsed a plan at its annual meeting to work with physicians and payers to make the screening more available and affordable.
Challenges with insurance coverage remain a barrier to colorectal cancer screening, despite extensive evidence that early screening decreases the likelihood of colorectal cancer and increases the likelihood of survival.
"One in three people is not up-to-date on their colorectal screening even though we know that if colorectal cancer is caught early, the five-year survival rate is 90 percent," said AMA Board Member Russ Kridel, M.D. "The AMA needs to help patients understand the value of screening and help them gain access to it."
Under the Affordable Care Act (ACA), private health insurance plans must cover colorectal cancer screening without imposing any cost-sharing on patients. Moreover, federal government guidance has clarified that ACA-compliant insurance plans cannot impose any patient cost sharing when a polyp is removed during a screening colonoscopy. Delegates endorsed an advocacy effort in support of Medicare coverage for colorectal cancer screenings consistent with ACA-compliant plan coverage requirements.
Medicare coverage differs critically from commercial coverage. Specifically, when a polyp or abnormal growth is removed during a colonoscopy, or when a biopsy is done of suspicious-looking tissue, the "screening" colonoscopy becomes "diagnostic," and although the Medicare Part B deductible is waived, beneficiaries are billed co-insurance of 20 percent of the cost of the procedure.
The differing coverage rules can lead to significant confusion, financial burden on patients, and finally, patients avoiding colorectal cancer screening.
Given the complicated coding and payment rules surrounding the screening, it is unsurprising that patients commonly find themselves billed for services they expected to be covered at no cost to them.
Delegates also called on the AMA to collaborate with physicians who specialize in colorectal screening to develop a coding guide to help physicians correctly bill various screening scenarios and promote common understanding among health care providers, payers, and patients so that all know what will be covered at given cost-sharing levels.