Preventive care: It’s free, except when it’s not


Published: Thursday, January 5, 2012 at 1:30 p.m.
Last Modified: Thursday, January 5, 2012 at 1:30 p.m.

Chicago

Facts

COVERED SERVICES

A partial list of services that should be covered without copays or other cost-sharing by the patient:

* Alcohol misuse screening and counseling.

* Aspirin use for men and women of certain ages.

* Blood pressure screening for all adults.

* Cholesterol screening for adults of certain ages or at higher risk.

* Colorectal cancer screening for adults, starting at age 50.

* Depression screening for adults.

* Type 2 diabetes screening for adults with high blood pressure.

* Diet counseling for adults at higher risk for chronic disease.

* HIV screening for all adults at higher risk.

* Flu shots and other recommended vaccines for adults and children.

* Obesity screening and counseling for adults and children.

* Tobacco use screening for all adults and cessation interventions for tobacco users.

* Breast cancer mammography screenings every 1 to 2 years for women over 40.

* Cervical cancer screening for sexually active women.

* Folic acid supplements for women who may become pregnant.

* Osteoporosis screening for women over age 60 depending on risk factors.

* Autism screening for children at 18 and 24 months.

* Depression screening for adolescents.

* Fluoride supplements for children without fluoride in their water source.

* Hearing screening for all newborns.

Bill Dunphy thought his colonoscopy would be free.

His insurance company told him it would be covered 100 percent, with no copayment from him and no charge against his deductible. The nation's 1-year-old health law 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."

President Barack Obama's health overhaul encourages prevention by requiring most insurance plans to pay for preventive care. On the plus side, 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.

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.

Florida's consumer services office also reports complaints about colonoscopies and other preventive care. California insurance broker Bonnie Milani said she's lost count of the complaints she's had about bills clients have received for preventive services.

"‘Confusion' is not the word I'd apply to the medical offices producing the bills," Milani said. "The word that comes to mind for me ain't nearly so nice."

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