CHICAGO (AP) — Bill Dunphy thought his colonoscopy would be free.
His insurance company told him it would be covered 100% with no copayment from him and no charge against his deductible. The Patient Protection and Affordable Care Act of 2010 (PPACA) now requires most insurance plans to cover all costs for preventive care including colon cancer screening. So Dunphy had the procedure in April.
Then the bill arrived: $1,100.
Dunphy, a 61-year-old Phoenix small business owner, angrily paid it out of his own pocket because of what some prevention advocates call a loophole. His doctor removed two noncancerous polyps during the colonoscopy. So while Dunphy was sedated, his preventive screening turned into a diagnostic procedure. That allowed his insurance company to bill him.
Like many Americans, Dunphy has a high-deductible insurance plan. He hadn’t spent his deductible yet. So, on top of his $400 monthly premium, he had to pay the bill.
“That’s bait and switch,” Dunphy said. “If it isn’t fraud, it’s immoral.”
Obama administration officials say that, in part because of the PPACA preventive care coverage provision, more than 22 million Medicare patients and many more Americans with private insurance have received one or more free covered preventive services this year. From cancer screenings to flu shots, many services no longer cost patients money.
But there are confusing exceptions. As Dunphy found out, colonoscopies can go from free to pricey while the patient is under anesthesia.
Breast cancer screenings can cause confusion too. In Florida, Tampa Bay-area small business owner Dawn Thomas, 50, went for a screening mammogram. But she was told by hospital staff that her mammogram would be a diagnostic test — not preventive screening — because a previous mammogram had found something suspicious. (It turned out to be nothing.)
Knowing that would cost her $700, and knowing her doctor had ordered a screening mammogram, Thomas stood her ground.
“Either I get a screening today or I’m putting my clothes back on and I’m leaving,” she remembers telling the hospital staff. It worked. Her mammogram was counted as preventive and she got it for free.
“A lot of women … are getting labeled with that diagnostic code and having to pay year after year for that,” Thomas said. “It’s a loophole so insurance companies don’t have to pay for it.”
For parents with several children, costs can pile up with unexpected copays for kids needing shots. Even when copays are inexpensive, they can blemish a patient-doctor relationship. Robin Brassner of Jersey City, N.J., expected her doctor visit to be free. All she wanted was a flu shot. But the doctor charged her a $20 copay.
“He said no one really comes in for just a flu shot. They inevitably mention another ailment, so he charges,” Brassner said. As a new patient, she didn’t want to start the relationship by complaining, but she left feeling irritated. “Next time, I’ll be a little more assertive about it,” she said.
How confused are doctors?
“Extremely,” said Cheryl Gregg Fahrenholz, an Ohio consultant who works with physicians. It’s common for doctors to deal with 200 different insurance plans. And some older plans are exempt.