Chantal Panozzo and her husband, who live in a Chicago suburb, are counting on their first routine colonoscopy to be free and fully covered by their insurance as preventive care under federal law.
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Chantal Panozzo and her husband, who live in a Chicago suburb, are counting on their first routine colonoscopy to be free and fully covered by their insurance as preventive care under federal law.
Taylor Glasscock/KFF Health News
Chantal Panozzo and her husband followed their doctor's instructions last year after turning 45, the recommended age to start screening for colorectal cancer. They scheduled their first routine colonoscopies several months apart.
Panozzo said she was more excited about getting the colonoscopy than anything else. Because it means free treatment. The couple runs their business from a suburban home near Chicago and has insurance that costs their family of four more than $1,400 a month on the state health insurance exchange created by the Affordable Care Act.
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By law, patients have free access to preventive services, including regular colonoscopies. As such, Panozzo said he expects the screening to be fully covered.
“This was an opportunity to get free preventive care,” she said.
The results came back normal, she said.
Then the bill came.
Patients: Chantal Panozzo, now 46, and Brian Opied, 45, who use their maiden names professionally, are covered by Blue Cross and Blue Shield of Illinois.
Medical services: Two routine colonoscopies (one for him, one for her) for patients 45 years of age and older, as recommended by the U.S. Preventive Services Task Force.
Service provider: Illinois Gastroenterology Group in Hinsdale. The practice is part of the private equity-backed GI Alliance, which has more than 800 gastroenterologists in 15 states including Florida, Missouri and Texas.
Total bill: The gastroenterology group charged $2,034 for each colonoscopy, before insurance discounts and discounts. After discounts, Blue Cross and Blue Shield of Illinois said it was responsible for paying $395.18 for Brian's screening and $389.24 for Chantal.
However, apart from screening costs, the total included a $600 charge per patient. However, the original insurance documents did not list the nature of the claim. This left Chantal and Brian with bills of $250 each, an amount allowed by her BCBS in Illinois and applied to their deductible.
What you get: Panozzo and her husband's experience exposes loopholes in laws intended to guarantee zero-cost preventive services. Healthcare providers can bill in any way they choose, as long as they comply with their contracts with insurance. This includes any products or services you choose to feature. And in a way that can leave patients with unexpected bills for “free” care.
After the exam, Panozzo said she and her husband each saw the same strange $600 charge from Illinois Gastroenterology Group on their insurance benefit statements. The gastroenterology group's billing statement said the charges were for “surgical supplies.” Her insurance company eventually told her the code was for a “surgical tray.”
Panozzo said she was confused at first. “Why on earth did I receive a bill?”
The Affordable Care Act requires that preventive health services such as colonoscopies, mammograms, and cervical cancer tests be fully covered at no cost to patients.
Policymakers included this distinctive protection because cost can be a deterrent for many patients from seeking treatment. A 2022 KFF poll found that nearly four in 10 adults have skipped or postponed necessary care due to cost concerns.
However, under the law, it is the responsibility of insurance companies to ensure that patients have access to free preventive care. Sabrina Corlett, a research professor at Georgetown University and co-director of the Center on Health Care Reform, said health care providers could exploit this loophole.
“While the insurance company is supposed to pay the full amount, there is no requirement for the insurance company to correctly describe the claim,” Corlett said.
In this case, BCBS of Illinois paid for the entire cost of the couple's tests, according to its own documents. But those documents also showed each patient was made to pay a portion of the individual $600 fee.
Panozzo thought a call to BCBS, the Illinois insurance company, would quickly resolve the mistake. But she said she spent most of her time on hold and didn't get an answer as to why her colonoscopy would cost extra for supplies. She said that in subsequent correspondence with her insurance company, she learned the $600 was specifically for a “surgical tray.”
BCBS of Illinois declined to comment, even though it received a waiver authorizing the insurance company to discuss the matter.
Panozzo said she called the gastroenterology practice and was told by a billing representative that the surcharge was part of the practice's arrangement with BCBS. I recalled being told that this clinic was accustomed to entering billing codes for “surgical trays.” in lieu of a separate fee, which Mr. Panozzo described as a “fee for use” of the clinic.
“Everyone I talked to, I got a different story,” Panozzo said.
She said both sides are in a “no man's land” by telling the other party that they have a responsibility to drop the charges.
solution: Mr. Panozzo accepted her objections in full and filed an appeal with his insurance company to dispute the total amount owed of $500. She files a complaint with the Illinois Department of Insurance. And she sent a letter to elected officials warning that Illinois consumers were being “taken advantage of” and “ripped off.”
BCBS ultimately granted both appeals, saying neither Panozzo nor her husband planned to pay the fees.
Reached by phone at the Illinois Gastroenterology Group location where the couple was treated, administrative officials said they could not comment and asked KFF Health News to contact executives at the GI Alliance, the national organization that manages the practice. instructed. Neither management nor media representatives responded to multiple requests for comment.
Panozzo said she previously paid the fee to avoid wasting time haggling with doctors, insurance companies, or both. But would she be charged twice for the same bill? That was unacceptable to her, she said.
“If change is going to happen, I need to stop accepting some of these bills that I know are potentially wrong,” Panozzo said.
Key points: Health care providers have wide discretion to determine how to bill for health care, including determining how to identify goods and services provided. This means patients can be stuck with a bill for something unfamiliar or downright strange.
The law also doesn't dictate how health care providers bill patients for preventive services, which can lead to strange charges even for treatments that should be fully covered.
Research also shows that increasing private equity ownership in specialties such as gastroenterology can lead to increased costs for patients and decreased quality of care.
For patients, “there is no remedy under federal law,” Corlett said.
State regulators could go after these providers for charging patients for covered services, but that could be a complicated situation, Corlett said.
Insurers should crack down on this type of behavior with providers in their networks, Corlett said. Otherwise, patients will be caught in the middle, challenging the nature of their “free” medical care and being at the mercy of the insurance appeals process.
Health plans may not be able to detect billing anomalies. After all, with a major insurance company, a $600 claim may not be worth investigating. This ultimately leaves the onus on the patient to know how much they are being charged and to speak up if something looks suspicious.
Panozzo said the experience left her feeling defeated, exhausted and distrustful of the American health care system.
Having lived abroad with her family for nearly 10 years, she said, “I was able to function better in the health care system in German than I could here in English.”
Emmarie Huetteman of KFF Health News edited the digital story and Taunya English of KFF Health News edited the audio story. NPR's Will Stone edited the audio and digital story.
