Physicians and Patients Take On – and Win – the “Post Polypectomy Surprise” Billing Controversy
Organizing efforts led by physicians and advocacy groups have resulted in a new law removing a problematic barrier to colon cancer screening, and a big win for patients.
Current Colorectal Cancer Screening Guidelines
Colorectal cancer (CRC) is still a major public health issue but is largely preventable. The USPSTF currently recommends
Asymptomatic adults ≥45 years
50 to 75 years (A recommendation)
45 to 49 years (B recommendation)
Selectively offer screening in adults 76 to 85 years (C recommendation)
Guidance refers to individuals who are at average risk of CRC
No family history of known genetic disorders predisposing to high lifetime risk of CRC (e.g., Lynch syndrome or familial adenomatous polyposis)
No personal history of IBD, previous adenomatous polyp, or previous CRC
Grade A and B recommendations take on special importance because they specify that doctors and other healthcare professionals should ‘offer to provide this service’
What’s the Good News Regarding Grade A and B USPSTF Recommendations?
The Affordable Care Act (ACA) addresses reimbursement for preventative care with a focus on key professional recommendations including those of USPSTF. This means that health insurance plans must provide coverage resulting in no out-of-pocket payments for patients.
What Went Wrong?
Even prior to the ACA, there have been efforts to reduce the financial burdens associated with colorectal cancer screening. Starting in 2002, the Screen for Life Act sought to increase reimbursement for colorectal cancer screening and diagnostic tests and waived the deductible for colorectal cancer screening tests. With the 2010 Affordable Care Act, financial barriers to CRC screening have slowly disappeared. However, an unintended quirk in the law brought sticker shock to asymptomatic patients if a worrisome polyp was actually removed during a colonoscopy screening procedure. Even though the polypectomy would be considered standard of care (and considered a positive outcome of the screening procedure), the procedure was now considered therapeutic. Known as the ‘post polypectomy surprise’, the waiver of cost-sharing goes away and patients would have unexpected bills. This surprise expense was viewed as barrier to screening aside from being unfair to patients and physicians alike who are simply following best practices.
What Happened in January 2022?
The push back against the ‘post polypectomy surprise’ is an excellent example of how physicians can organize, along with the support of other advocacy groups, to address and reverse a problematic barrier to care. Once the billing issue became clear following the passage of the ACA, advocacy led to the passage of ‘The Removing Barriers to Colorectal Cancer Screening Act (S. 668; HR 1570)’. Thanks to these efforts, over the next eight years, starting on January 1, 2022, the Medicare beneficiary coinsurance that stands at 20% for when a polyp or other growth is found and removed as part of a screening colonoscopy or screening flexible sigmoidoscopy will be phased out to zero. The eight-year phase arises from the pay-as-you-go rule, also known as PAYGO. It requires to pay for such legislation by reducing other entitlement spending or increasing other revenues with the goal of limiting any expansion of the budget deficit.
Physician societies and organizations spent years of effort and resources to remove this barrier to care. Enactment of the ACA is associated with a significant 23% reduction in colorectal cancer cases and deaths. Dr. David Greenwald, President of the American College of Gastroenterology stated the following which should be a clarion call to physicians of all specialties about taking a stand on behalf of our patients
On behalf of the American College of Gastroenterology, I want to thank Congress for including the Removing Barriers to Colorectal Cancer Screening Act (S. 668; HR 1570) in the larger spending and COVID-19 relief packages today. This legislation is long overdue and will help increase colorectal cancer screening rates in the Medicare population. Thank you, Rep. Donald Payne, Jr. (D-NJ), Sen. Sherrod Brown (D-OH), and all current and former members of the U.S. Congress for championing this important bipartisan issue throughout the years. ACG is grateful to partner with many patient advocacy groups and professional societies, who have all joined together to get this passed through Congress
Colorectal cancer is still a major public health issue, yet still is largely preventable. Over 50,000 Americans are estimated to die from colorectal cancer this year. It does not take a pause due to COVID-19, or any other public health crisis. Thus, it is important for policy makers to do everything we can do to incentivize and increase colorectal cancer screening rates in the Medicare population
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