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A Catch 22 in colonoscopy coverage

In the debate over health care, here's something we can all agree on: We don't want surprises on our medical bills . . . things we thought were covered that really weren't. Take health screenings like mammograms. Most insurance plans promise to cover them fully, since catching a problem early can prevent much bigger expenses down the line. And insurance companies appear to make the same promise for colonoscopies, since colorectal cancer is one of the deadliest forms of cancer. However, many people are discovering their colonoscopy insurance benefit comes with strings. And some wake up from the procedure to discover they owe hundreds - even thousands - of dollars. "I think it's very deceitful the way it's currently marketed," says Dr. Stephen Deal, a gastroenterologist at Carolina Digestive Health in Charlotte. Lately he and his staff have been spending a lot of their time explaining to patients that, "Yes, you may think your health insurance covers a colonoscopy now that you're 50 years old, but if we find anything while we're scoping around in there, you'll have to foot the bill." "And that is the new little Catch 22 our patients are finding themselves in," says Deal. Before we go any further, here's a quick refresher on the procedure Deal calls a "moving experience" - a little doctor humor there. "The day before the test you're on a clear liquid diet that whole day," says Deal. "You'll get a series of laxatives that will make you move your bowels repeatedly. Because we need to get the stool out of the colon, so that we can see carefully and get a good inspection. The scope is introduced into your bottom and then it's advanced all the way around your colon." That's six feet of large intestine - all the while looking for polyps or lesions. If he finds them - and he says that happens up to 40 percent of the time - he cuts them out. Katie Couric did her part to encourage colonoscopy screening when she got hers on national TV back in 2000. Since then, 29 states - including North Carolina - have passed a law requiring insurance companies to cover colonoscopies. But the definition of "cover" is where patients get into trouble. "At the point that I find something and I take it out then you no longer have a screening procedure and you have a therapeutic procedure," says Dr. Stephen Deal. "And therefore your screening benefits don't kick in any longer, and if you happen to have a high deductible policy, that polyp removal may have just cost you a thousand dollars." Even though removing the polyp only added a hundred dollars or so to the overall cost of the colonoscopy, you're still on the hook for the entire thing. This seems to be pretty common for all insurance companies in North Carolina, and many other states. When Dr. Deal warns his patients about it, he says many opt out. "There are people who just say, you know I really can't afford that right now. I'll have to consider that later in the year," he says. "And we do not want that to happen," says Eric Koehler, a senior product developer for Blue Cross Blue Shield of North Carolina which is the dominant insurer in the state. Koehler says this colonoscopy issue is a top customer concern when it comes to preventative care. "We do use the input that our members give us through the customer service center," says Koehler. "And this is something that we are trying to address to meet member expectations." Koehler says it's mostly a problem with a relatively new, and increasingly popular, Blue Cross plan that has lower premiums but much higher deductibles. Koehler says other more comprehensive Blue Cross plans cover colonoscopies 100 percent no matter what the doctor finds - as long as it's done in a doctor's office and not a hospital, where the procedure can cost twice as much. Health reform advocate Adam Searing of the NC Justice Center sees the colonoscopy issue as a symptom of larger problem: People today are being asked to pay much higher deductibles. "Businesses still want to offer insurance, but the cost is so much the only way they can get that cost down is jack up these co-insurance costs and so people who get sick suddenly now realize they're on the hook for thousand dollars whereas five or six years ago that wouldn't have been the case," says Searing. In the last three years, the percentage of people with a deductible higher than a thousand dollars has doubled, according to the Kaiser Family Foundation. Couple that with new research that finds the number one reason people don't get a colonoscopy is cost, and you have what Concord resident Dianne Ericson considers a disastrous situation. "I know money's an issue, but do you want that $3,500 in your pocket or do you want to be alive next year? That's pretty much the choice they're making." Ericson should know. She was diagnosed with advanced colon cancer in 2006. Just last year her husband had a routine colonoscopy that uncovered a polyp. Luckily, it wasn't cancer. But they still had to pay $700 out of pocket, because of the same Catch 22 in their screening benefits that is catching so many others by surprise.