June 02, 2023

More Screening, Fewer Bills: A Win for Patients and Providers in the Fight Against Colorectal Cancer

New guidance directs health plans to cover a follow-up colonoscopy, without any cost to patients.

Mature patient meets with her doctor
Note: A March 2023 ruling in federal district court would roll back some Affordable Care Act provisions for many preventive services described below. That ruling has since been paused until the appeals court can rule on the case. This article will be updated as needed.

Imagine: A patient takes a non-invasive colorectal cancer (CRC) screening test, and it comes back positive.

Because of the positive result, the patient heads to a colonoscopy to confirm the screening result and figure out what’s next.

That patient might be worried. Distracted. Angry. Panicky. However they’re feeling, they’ve got a lot on their mind.

A recent change to federal health care policy intends to take away one concern: that the patient will get a bill for that colonoscopy.

Under the Affordable Care Act (ACA) and guidelines from the Centers for Medicare & Medicaid Services, private insurers and Medicare have to cover recommended colorectal cancer screening without any out-of-pocket costs for patients.

But until recently, a colonoscopy to confirm a positive stool-based test result fell into a gray area. The procedure wasn’t always covered, even though colorectal cancer is one of the most common types of cancer and has a five-year survival rate of 91% when found in early stages through screening.1

Starting in 2023, new guidance went into effect, requiring health plans to cover a follow-up colonoscopy, without any cost to patients.

Here’s a look at how we got here and how things are expected to change.

All in the coding

Clinicians use a vast coding system to tell health plans or other payers what services they have provided to their patients.

Under the ACA — but before this policy change — most payers would cover an average-risk patient’s choice of CRC screening methods, if the procedure had an A or B grade from the U.S. Preventive Services Task Force. A patient could opt for a colonoscopy or other invasive procedure. Or they could choose a non-invasive option, including an at-home stool DNA and hemoglobin test (Cologuard®) or a fecal immunochemical test.

Any of those choices was considered a screening test, or a test given to a patient who didn’t show signs or symptoms of a disease.2 Doctors coded them that way to health plans, and patients didn’t get billed.

When a non-invasive screening test delivered a positive result, though, the patient needed a colonoscopy to confirm the results. Even though a colonoscopy was the next step in the screening process and would have been covered if the patient had chosen it initially, payers and clinicians often considered this colonoscopy a diagnostic test — meaning, a test given after signs or symptoms have appeared.3

When a colonoscopy is coded as diagnostic, that’s when co-pays and deductibles kick in4 and patients get billed. Many of those bills surprised patients, and the costs associated with follow-up colonoscopy created barriers to people completing CRC screening.5 Something needed to change.

Part of the screening continuum

Several cancer advocacy organizations — the American Gastroenterological Association, the American Cancer Society Cancer Action Network and Fight Colorectal Cancer — banded together to tackle the issue. They collaborated with other advocacy groups and industry partners, including Cologuard maker Exact Sciences, to improve these policies for patients.

The organizations made the case that it was silly to create cost barriers that kept patients from completing this critical step in the CRC screening process. 

And their efforts paid off. The federal government agreed that a follow-up colonoscopy completed the screening process. In early 2022, the government issued guidance requiring commercials payers to make the procedure free for patients.6

Even better, the Centers for Medicare & Medicaid Services quickly followed suit, announcing it would expand the definition of CRC screening to include the colonoscopy following a positive stool-based test, beginning in 2023. It also shared updated coding for clinicians.7

“We now understand both the non-invasive, stool-based test and the follow-[up] colonoscopy are both part of a continuum of a complete CRC screening,” the agency said in a message to health care providers.

What this means for the fight against colorectal cancer

Cancer affects everyone in some way, but it doesn’t impact all populations equally. Black Americans are more likely to develop CRC than any other racial group and are more likely to be diagnosed in later stages, when outcomes are worse. Hispanic Americans have the second-highest death rate due to CRC, after Black Americans.8

The reignited federal Cancer Moonshot, which aims to reduce cancer mortality by half in the next 25 years, calls attention to the role that better screening access could play in improving figures like these. According to the National Cancer Plan, which acts as the Moonshot’s roadmap, “Many eligible people are not getting tested, and we need to better understand why there are disparities in screening and early detection rates across different populations.”

The advocacy organization Fight Colorectal Cancer works to ensure that all Americans can access quality health care and live healthy lives. Anjee Davis, MPPA, the group’s president, said that the follow-up colonoscopy policy change will reduce health care inequities by giving people more flexibility in getting screened. 

“Non-invasive colorectal cancer screening tests are an important tool in the fight against colorectal cancer, particularly in light of challenges patients have faced due to COVID-19 and as we expand our efforts to reach medically underserved communities,” Davis said.

Dr. David Lieberman agrees. He serves as chairperson of the American Gastroenterological Association committee on CRC screening.

“We know disparities exist in CRC screening,” Lieberman said. “There are data which show that when we increase access to colorectal cancer screening and help navigate patients needing a follow-up colonoscopy after a non-invasive screening test, those disparities are greatly reduced.”

What this means for patients

People now can select a screening test with more confidence that a needed colonoscopy will be covered, Davis said.

“This guidance will help ensure that patients can choose the test that is best for them without worrying about out-of-pocket costs for a follow-up colonoscopy,” she said. “Ultimately, we believe this will save lives and support an increase in the early detection of colorectal cancer.”

Although most payers are required to cover CRC screening at no cost to the patient, exceptions apply. A patient should check with their insurer about what will be covered.

Understandably, it can take time for providers to incorporate policy changes and coding updates like this one. Many in the field are working hard to educate health care providers about the new policy. If patients do need help, they can explore:

o   The American Gastroenterological Association’s guide to help people respond to unexpected bills
o   Information from Exact Sciences’ Cologuard about understanding insurance coverage for follow-up colonoscopy
o   Fight Colorectal Cancer’s screening and coverage guide

What this means for clinicians

The policy change makes complete CRC screenings free to more people. It also will reduce surprise billing for patients. Clinicians play a lead role in unlocking this benefit for patients — and it all goes back to how they code tests.

To support clinicians through this policy change, the American Gastroenterological Association offers a coding guide for reimbursement of CRC screening and answers to frequently asked coding questions. Fight CRC also offers a toolkit of resources for clinicians, with advice about screening, coding and discussing billing with patients.

Said the AGA’s Lieberman: “This change will help providers address a major CRC screening gap for people who were previously burdened by the cost of a follow-up colonoscopy.

“This is a huge win for our patients.”

1. https://www.cancer.org/cancer/colon-rectal-cancer/prevention-infographic.html
2. https://gastro.org/practice-resources/reimbursement/coding/coding-faq-screening-colonoscopy/
3. https://gastro.org/practice-resources/reimbursement/coding/coding-faq-screening-colonoscopy/
4. https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/screening-coverage-laws.html
5. A.M. Fendrick, N. Princic, L.-A. Miller-Wilson, K. Wilson, P. Limburg, Out-of-Pocket Costs for Colonoscopy After Noninvasive Colorectal Cancer Screening Among US Adults with Commercial and Medicare Insurance
6. https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-51.pdf, p 12.
7. https://www.cms.gov/files/document/mm13017-removal-national-coverage-determination-expansion-coverage-colorectal-cancer-screening.pdf
8. Annual Report to the Nation on the Status of Cancer, Part I: National Cancer Statistics. Henley; 2021.