Gift cards for colon cancer screening were recently approved for distribution under certain conditions by the Office of the Inspector General (OIG) of the Department of Health and Human Services, according to online reports.
The name of the company issuing gift cards and winning the ruling was not specified, making the act a little bit mysterious.
The ruling approved “a proposal by the manufacturer of a colorectal cancer screening test and its wholly owned laboratory to provide gift cards to certain patients to encourage them to return the sample collection kits,” Bass Berry Sims, a law firm, wrote in a post on its site.
Why should we care? The law firm writes: “While limited in scope, this favorable opinion is noteworthy because OIG typically disfavors arrangements under which providers or suppliers distribute gift cards to incentivize patients to obtain federally reimbursable services.” Colon cancer screening is supposed to be covered without cost under the Affordable Care Act, in accordance with U.S. Preventive Services Task Force guidelines.
The requestors are “the manufacturer of the first and only FDA-approved, non-invasive test for detecting signs of colorectal cancer and its wholly owned laboratory, which performs and processes the tests,” the law firm’s article wrote. “The requestors certified that at least 30% of all patients who receive a test kit based on a physician’s order do not return the kit to the laboratory for evaluation.” So the gift card incentive is to encourage the return of the kit, and theoretically reduce colon cancer deaths (while also making money for the manufacturer).
Mail-in kit
The requester is almost certainly Cologuard, the manufacturer of a popular at-home kit that is widely advertised, and frequently used by those who want to avoid the full colonoscopy experience. The kit is mailed or given to the patient, who collects a sample at home and mails the kit back to the company.
The full 12-page opinion, with the company’s name edited out, is here.
The law firm wrote that under the agreement, if the lab doesn’t get the test kit in a timely fashion, after at least two tries, the lab would send the patient a reminder letter telling them they will get a prepaid gift card of up to $75 if they return the kit by a specified deadline.
“The requestors would provide gift cards to patients only once every 36 months – a timeframe that complies with the [U.S. Preventive Services Task Force] recommendation that all adults ages 45-75 receive the test every 1-3 years and Medicare’s reimbursement of the test every 36 months.”
“Though the OIG noted that the gift cards implicate the federal Anti-Kickback Statute (AKS) and the Beneficiary Inducements CMP because they would influence patients to receive reimbursable services from the requestor, the OIG concluded that the arrangement presented a minimal level of risk,” the National Law Review wrote.
My own doctor said she has prescribed Cologuard screening for patients who are reluctant to go for the full-on colonoscopy. As a way of encouraging screening, she says, it is a good alternative to people who don’t want to do the full-on experience.
Colon cancer can be highly treatable if caught early. Colonoscopies are free to most people over age 45 under the A.C.A. Colon cancer rates are rising, especially among younger people and in communities of color.
When the Cologuard experience goes wrong
That Cologuard won this ruling is interesting. In our partnership with CBS News, we did a story about how patients using Cologuard screening might find, if they get a positive result, they are referred for a full colonoscopy. That follow-on full colonoscopy might be billed as a diagnostic procedure, which is a “sick person” visit, as opposed to a preventive procedure, which is supposed to be covered under the Affordable Care Act. (While a Texas judge ruled recently that no preventive care costs need be paid, effectively throwing out the entire preventive care benefit in the Affordable Care Act, that ruling is under appeal.)
One woman was billed nearly $2,000 for such a colonoscopy, after having a positive Cologuard result, we learned.
The full colonoscopy procedure is billed as preventive, but it also has aspects of treatment. For example, if a polyp is found that is determined to be pre-cancerous, its removal has health benefits that go beyond simply noting its presence.
“Under the Affordable Care Act, only routine screening tests are covered, and because Bryant’s Cologuard result was positive, her colonoscopy was coded as a ‘diagnostic’ test, which was not fully covered by her insurance,” CBS wrote. “She would have been fully covered if she had not used Cologuard first.”
My own doctor had never heard of such a case, and it wasn’t clear to us how often this happens.
Why did this particular gift card arrangement win approval? “The OIG concluded that the gift cards satisfied the Preventive Care exception to the Beneficiary Inducements CMP, which applies to incentives given to individuals to promote the delivery of preventive care services where the delivery of the services is not tied to the provision of other services reimbursed by federal health care programs,” the National Law Review wrote of the ruling.
“One requirement of the Preventive Care exception is that the incentive (e.g., the gifts card) cannot be disproportionally large in relationship to the value of the preventive care service, and Medicare reimburses $500 for the colorectal cancer screening. The OIG stated that, under a different set of facts, a $75 incentive might be disproportionally large in relationship to a preventive care service valued at $500.
“But the exception also takes into account the future health care costs reasonably expected to be avoided as a result of the preventive services, which evidently led the OIG to give more weight to the value of the colorectal screening.”
How much does a colonoscopy cost?
For more information, here’s our post on “how much does a colonoscopy cost.” Don’t miss the passage about all the component parts — doctor’s fee, anesthesia (if used), pathology, facility fee, etc.
Increasingly, we have heard of patients who are not able to get insurance company approval for a colonoscopy, even if they are at risk because of a family history of colorectal cancer. While often a doctor’s note can cause an insurance company to change its ruling, sometimes that is not effective. Insurers typically say that they are adhering to U.S. Preventive Services Task Force guidelines. (Insurance companies love to deny claims.) We have also heard that insurance companies sometimes approve a procedure, then refuse to pay. In that case, we’re not sure what approval means, but we have heard this not infrequently.
In such a case, it’s possible that paying for a colonoscopy out of pocket, on cash rather than using your insurance, will give you the peace of mind you are seeking.
If you go this route, you’ll want to find out what something costs on cash by calling providers (see here and here and here) and looking at the “how much does a colonoscopy cost” post above, and/or searching our database. That sticker price of, say, $6,000 or so (we’ve seen much higher, too) might easily be closer to $1,000 on cash if you do your homework.
Pro tip: Take care to get everything in writing. It is important to tell them in advance that you are a cash customer — if it gets sent in to the insurance company, the sticker price of $6,000 or whatever, rather than the cash price, may land on you, because of insurer-provider contracts.
Cologuard might be an option, as is the fecal immunochemical test (FIT), which comes in many forms. We have seen sticker prices of $500 to $681 for Cologuard, though this is anecdotal. As always, we are not giving medical advice.
