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A provision in the Affordable Care Act that waived patients' payments for colonoscopies is an example of how good intentions in the law can lead to a tangle of unforeseen consequences.

Colonoscopies are on the ACA's list of screening procedures for which patients are not supposed to pay a cost share -- the deductible and copayment. The requirement took effect in September 2010 and applies to most members of health plans.

This provision has been widely praised. At a time when rising deductibles can push the patient's cost share for a colonoscopy to well over $1,000, financial disincentives are removed for a procedure that clearly .

Reality Behind "Good Concept"

However, insurance plans are still forcing colonoscopy patients to pay the cost share in many cases.

Until recently, for example, many plans were charging patients whenever a polyp was found during the procedure. Patients would go in thinking they were getting a free screening and come out with a big bill when one or more polyps were found. Insurers would argue that finding and removing the polyp turned the screening into a therapeutic procedure, which is not supposed to be covered by the provision.

In February, the Obama administration overruled that interpretation, holding that the patient doesn't have to pay a cost share when a polyp is found. "," the Department of Labor stated.

But this ruling did not stop insurers from finding new ways to impose a cost share. While many payers waive the cost share without quibbling, many others still make stipulations, says Amy Fasti, vice president of billing services at Physicians Endoscopy, an operator of endoscopy centers based in Jamison, Penn.

"It feels like a game sometimes," Fasti says. When a cost share is imposed, billing staff has to appeal the denial and discuss the law with the recalcitrant payer. In many cases, she says, the appeal is successful, but it takes a lot of work.

For example, when a polyp is found, insurers are now charging the patient for the next colonoscopy, arguing that the patient is no longer symptom-free and the colonoscopy has become a "diagnostic" or "surveillance" procedure.

For instance, , United Healthcare states that when the patient has a polyp removed, "all future colonoscopies are considered diagnostic," and thus require a cost share. This has a major impact, , requiring the patient to go back for a follow-up usually in 2 to 5 years.

The cost share for colonoscopies has been required in many other situations, as well, according to two different surveys of payers by the and the . The situations include colonoscopies on patients with a family history of colon cancer and on patients reporting slight pains, as well as colonoscopies ordered after a positive result on a fecal occult blood test, billed with codes not accepted by a particular insurer or performed by out-of-network providers.

Lost in translation

Charging a cost share for colonoscopies goes against the intention of the healthcare law of making it easier for people to have the procedure done, says Robert A. Smith, PhD, senior director of screening at the American Cancer Society, who advised drafters of the ACA on the wording of the law's provision. "The intent of the law has gotten lost in translation," Smith says.

A key step in translating the ACA into insurers' rules is the evaluation of U.S. Preventive Services Task Force, an independent group of experts. For years, the task force has been determining the effectiveness of each screening procedure, and the law uses these evaluations to determine whether a procedure is effective enough to merit waiving the cost share.

The task force gave colonoscopy an A grade, the highest rating for effectiveness, but this hasn't stopped payers from finding exceptions. The stakes are high, because colonoscopy is one of the most expensive procedures on the law's list of preventive services. It has an estimated in the United States.

Aetna requires a cost share for patients with a history of polyps and bases this decision on the task force's evaluation, says Robert McDonough, MD, head of clinical policy research and development at Aetna. He points to that when "clinically significant colorectal adenomas," i.e., polyps, have been found, "the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable."

However, Brian C. Jacobson, MD, chair of the Health and Public Policy Committee of the American Society for Gastrointestinal Endoscopy (ASGE), has a different reading of that statement. "It's not saying that preventive screening is no longer necessary in this patient population," he says. "Rather, it is saying that these patients may require different screening regimens compared to the average risk population." By email, he added: "For these high-risk patients, screening may be more frequent, but it still constitutes preventive screening," meaning that cost sharing should be waived.

Dr. McDonough at Aetna noted that the statement he cited is seemingly contradicted by another task force statement. The task force only addresses situations where patients are asymptomatic, which could rule out patients with a history of polyps if you think of a polyp as a symptom. However, Dr. McDonough pointed to a task force statement that which suggests that patients with polyps would be included.

Using this statement, Dr. McDonough said, "You could make an argument that polyps are considered a preclinical disease," and thus there would be no cost share. In fact, "We've had some internal debates with colleagues about this," he said, but in the end, Aetna decided to ignore the contradictory statement.

"It does not help us to do a whole lot of over-thinking," Dr. McDonough said. "You have to follow the guidelines, regardless of whether you believe that they are being consistent."

One would think that the task force itself would be able to settle these uncertainties, but this independent, scientific body doesn't see itself as the arbiter for the healthcare law. Task force members "only consider the evidence on the benefits or harms of a service, and wouldn't have the answers to questions about what is covered or not covered [under the ACA]," said Ana Fullmer, a spokesperson for the task force.

When queried by email, Michael LeFevre, MD, a family physician who is co-vice chair of the USPSTF task force, would not say if colonoscopies on patients with a history of polyps were subject to the waiver of the cost share.

But he did observe that the task force is "looking for cancer precursors (adenomatous polyps) that can removed before they can evolve into cancer."

However, "We don't actually know how much of the benefit of screening for colon cancer is related to finding early cancers versus treating the precursor lesions," he added.

What practices can do

When patients get angry about the lack of clarity on paying for a colonoscopy, practices often get caught in the crossfire and are blamed for not sufficiently warning them about possibility of payment. The American Gastroenterological Association advises practices to make sure patients understand that they could be charged for a colonoscopy .

Many experts advise practices to contact the insurer and determine in advance whether the patient will be covered. This helps ensure payment, because patients are less likely to pay when they find out after the procedure.

The AGA also provides questions gastroenterologists could ask referring primary care physicians about the patient's symptoms to help determine whether the patient would have to pay the cost share.

For example, patients who have symptoms of GI diseases will likely have to pay the cost share or a colonoscopy.

Coding is another problem. Claims for colonoscopies can be coded in a number of ways to indicate that the procedure was a screening, but the automated claims processing system for a particular insurer may only accept certain diagnosis codes, billing experts say.

In January 2012, CPT modifier 33 was introduced to indicate a screening procedure where the cost share should be waived, but some insurers reportedly can't process it yet.

If insurers refuse to waive cost sharing, the practice or patient can always appeal.

"We usually win on an appeal," said Laurie Isner, who processes claims at Digestive Care Physicians in Cumming, Ga. Meanwhile, she expects the confusion about waiving cost share to continue. "This could take years to resolve," she said.

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