Addressing Health Plan Coverage Incentives —
Coalition Board
Jere Pittner, one of the founding Coalition Board members, is a recognized expert and innovator in the healthcare “practice management” field. Among other accomplishments, she co-founded Galen Advisors in early 2008. Galen Advisors provides guidance to physician groups looking to function more efficiently by offering operational and outsourcing support – as well as aiding clients in the development of ancillary service centers that expand the continuum of patient care. Ms. Pittner has a unique perspective on barriers to colorectal cancer (CRC) screening due to her extensive experience negotiating on behalf of several GI practices with insurance companies.
Coalition: Jere, you have worked with some of the largest gastroenterology practices in the country, what do you see as some of the current challenges in colorectal cancer screening?
JP: One of the biggest challenges that Gastroenterology practices face today is the discrepancy between coverage for colonoscopies as a wellness benefit and coverage for colonoscopies when they become a therapeutic procedure. Wellness benefits often afford patients much better coverage compared to standard benefits. Often, a person makes an appointment for a screening colonoscopy because they have the benefit as part of their wellness plan. When they are undergoing the procedure and the doctor finds a polyp, he or she removes it, called a polypectomy. This action changes the classification of the procedure from ‘screening’ to ‘therapeutic’ and the benefit from wellness to traditional coverage. Unfortunately, the result can be higher cost to the patients.
Coalition: So a patient arrives in the office anticipating a minimal or no cost because the screening is part of a wellness plan, and they are disappointed to learn that they are responsible for a large bill?
JP: Yes. The way most insurance carriers classify the two procedures creates a lot of headaches and frustration for both patients and practices. The wellness benefit should remain in place for the procedure, regardless of whether or not it becomes therapeutic, because the point of the screening benefit is to prevent cancer. When we actually do PREVENT CANCER by removing polyps, the patient is penalized with fees. Most lay people don’t understand, so they call the insurance company and are told that different ‘codes’ mean different benefits. They take it to mean that the physician’s office used the wrong code. The patient then calls the office and says that we’ve used the wrong code and want it changed. Obviously, we want to help them out but there is no way we can change the code.
Coalition: It sounds as though you see a need for widespread policy changes among health plans and insurance companies in regards to preventative care. Where should it start and how can physicians who may read this newsletter help?
JP: The varying benefits of ‘wellness coverage’ make screening more challenging than it needs to be. Carriers should alter the benefit description so polypectomies and colonoscopies are treated equally and they can honor the benefit as if it had stayed just a screening.
Coalition: What can physicians do to help reduce these and other deterrents to screening?
JP: Joining groups such as Preventing Colorectal Cancer.Org is a starting point. Physicians need to be aware of these issues and feel confident that if we work together we can affect a policy change. Also, individual physicians and practices can make changes within their office to make self-pay fee schedules more affordable. Practices that I’ve worked with try to keep the fee schedule close to the Medicare reimbursement rate. It makes sense because the people who don’t have excellent medical insurance are typically the ones who can least afford the ‘rack rate.’ When a patient is denied coverage for a polypectomy or access to deep sedation, they should be able to receive a reduced fee- not the opposite.
CALL-ON-CONGRESS 2010
If you are interested in taking your concerns to the Halls fo Congress, plan to join Preventing Colorectal Cancer.Org as we rally with the Colorectal Cancer Coalition (C3), another cancer advocacy group, for two days of training, lobbying and grassroots advocacy. You'll meet with your members of Congress and their staff to urge greater support of colorectal cancer legislation.
Mark your calendars for advocacy training on March 16th and meeting your members of Congress on the 17th.
