NC Department of Insurance : mandated colorectal screening is 'covered' but not 'reimbursed': SO WHAT KIND OF DOUBLE-SPEAK IS THAT?

This is a letter to me, in its entirety, from the NC Department of Insurance, Robert Lisson, PhD, Deputy Commissioner, Consumer Services Division.

This is what the Deputy Commissioner is stating: while state law mandates there be coverage of colorectal screening, the Department of INsurance cannot mandate BCBSNC as re: 'place of coverage'----though this results in non-coverage of colorectal screening----which is the law.

These appear to be the important points associated w/ the 'covered' but lack of 'reimbursement' of colorectal screening by BCBSNC except in an office based setting, of which one site is available and that site is in western NC, in Boone, NC.

Important item #1. colorectal screening is mandated to be covered under NC law, specifically, North Carolina General Statute 58-3-179 . Here is the law:

******************

http://www.ncleg.net/enactedlegislation/
statutes/pdf/bysection/chapter_58/gs_58-3-179.pdf

§ 58-3-179. Coverage for colorectal cancer screening.
(a) Every health benefit plan, as defined in G.S. 58-3-167, shall provide coverage
for colorectal cancer examinations and laboratory tests for cancer, in accordance with themost recently published American Cancer Society guidelines or guidelines adopted by
the North Carolina Advisory Committee on Cancer Coordination and Control for
colorectal cancer screening, for any nonsymptomatic covered individual who is:

(1) At least 50 years of age, or

(2) Less than 50 years of age and at high risk for colorectal cancer
according to the most recently published colorectal cancer screening
guidelines of the American Cancer Society or guidelines adopted by the
North Carolina Advisory Committee on Cancer Coordination and
Control.

The same deductibles, coinsurance, and other limitations as apply to similar services
covered under the plan apply to coverage for colorectal examinations and laboratory tests
required to be covered under this section.
(b) Reserved for future codification purposes. (2001-116, s. 1.)

****************

Important Item #2. "The same deductibles, coinsurance, and other limitations as apply to similar services....(are) required to be covered under this section."

Insurance policies have deductibles. Mine is a standard policy with a $2500.00/ year/ person deductible for the usual kinds of things: you get into an accident and you have to stay in the hospital. One expects to pay out of pocket for this. Your son has to have surgery for a condition that was congenital. One expects to pay out of pocket for this. You have to have surgery for something. One expects to pay out of pocket for this. And so are 'similar services' associated with:

a. outpatient services which may be necessary but are not covered by law
OR
b. a service which is covered by law

What is the definition of 'similar services'??

Important Item #3: If a service is covered by law, then why are other matters e.g., 'place of service' allowed to trump the law? If there are no office based gastroenterology practices which provide office based screening colonoscopies within 3 hours of a major metropolis in NC, then de facto isn't there essentially no coverage of the mandated service, specifically, screening colonoscopy?

****************


December 15, 2008
Dr. Marsha Hammond
--------------------------
Asheville, NC 28806

RE: Blue Cross & Blue Shield of North Carolina
------------------- -.­
Dear Dr. Hammond:

Thank you for your recent correspondence to the Consumer Services Division. I am writing in response to your December 13, 2008 em ail message to Becky Thornton, regarding your BCBSNC policy's coverage for colonoscopies in your immediate area.

First, "coverage" and "reimbursement" are two different things. North Carolina health plans subject to North Carolina General Statute 58-3-179 must indeed cover colorectal cancer screening. As you are aware, though, a claim for "covered" services does not always result in reimbursement from the health plan. . For example this could occur when (even after the cost of the covered service) the member has not yet met the applicable policy deductible. In such situations, the cost of the covered service is credited to the member's deductible. If the service were not covered, the cost would not be credited to the deductible.

Second, North Carolina law does not give the Department of Insurance the regulatory authority to dictate place-of-service for this mandated benefit. More specifically, we do not have the authority to require BCBSNC to make the procedure in question available in office-based settings. My understanding is that the procedure can be obtained from in-network BCBSNC providers in your immediate area. Whether the service is available only in contracted clinic settings or also from contracted office-based providers does not affect BCBSNC's compliance with applicable provider availability/accessibility requirements.

We certainly understand your disappointment, and regret that we do not have the authority to further assist you. However, please do not hesitate to contact me at (800) 546-5664 if you wish to discuss the matter.

Robert C. Lisson, Ph.D.
Deputy Commissioner, Consumer Services Division

With the Obama plan, the private insurance companies would HAVE to give the over 50-something access to screening colonoscopies in accord w/ Medicare

HEY! Before someone decides to rescue BCBSNC from its $50 million bottomless pit, you might consider that they will surely go under if they are not able to offer major components of the Medicare plan which are already in place-----like the access to a screening colonoscopy for NC citizens----because citizens will CHOOSE a public plan, like Medicare, over BCBSNC.

*************

http://www.emaxhealth.com/1/72/27785/
public-health-insurance-plan-option-quot-non-negotiable-quot.html

Public Health Insurance Plan Option "Non-Negotiable"

"......Advocates of a government alternative to private health insurance fired the first shot of the new battle to reform the nation’s health-care system on Wednesday, saying that efforts to water down this key component of Barack Obama’s health-care plan should be rejected by members of Congress.

“In the absence of a public plan you would have to so strictly regulate [private] health plans that they would all have to become public plans,” said Rep. Pete Stark, D-Calif., chairman of the House Ways and Means Health sub-committee.

"Stark spoke out on Wednesday because he is concerned that any effort to reform the private health-insurance market will prove ineffective if Americans are not offered the kind of Medicare-style government option contained in Obama’s 2008 campaign proposal.

"Stark’s concerns were echoed by Health Care Now, a liberal advocacy group.

“We agree with Congressman Stark that a health care solution that does not include a public plan would be a non-starter,” said Richard Kirsch, the national campaign manager for Health Care for America Now. “President-elect Obama ran on the promise of giving consumers a choice of keeping the private insurance they have or opting in to a newly-created public insurance plan, and it is the second part of this hybrid reform that ensures we are no longer at the mercy of the private insurance industry which keeps charging us more, giving us less, and lining its own pockets with profits.”

That red line is being drawn for a reason. Insisting upon a public plan option is not ideology for ideology's sake. It's critical to achieve quality, affordable health care for all.

Colonoscopy: sees only right side of colon but still diminishes death from colon cancer by 60-70%

Colonoscopies have blind side, study says
Popular test to detect signs of cancer only effective on left side of colon, review of 10,000 cases finds
December 16, 2008
Megan Ogilvie (cut and paste URL):
http://www.healthzone.ca/
health/article/554384#comments

A popular screening test for colon cancer is less accurate and prevents fewer deaths than doctors commonly believe, Toronto researchers say.

Their study, published yesterday, found colonoscopies are only effective at catching cancers that develop on the left side of the colon, and miss almost all cancers that start on the right side.

"All of the benefit of colonoscopy – and we know it reduces colon cancer deaths – is virtually related to the reduction of deaths from cancers arising in the lower, or left side, of the colon," said Dr. Linda Rabeneck of Cancer Care Ontario, the study's senior author.

For patients with cancer that developed on the colon's right side, a colonoscopy only reduced the risk of death by 1 per cent, she said.

Experts say the study, published in the journal Annals of Internal Medicine, will help doctors understand the limitations of colonoscopy and spur efforts to improve the test's monitoring of the right colon. They say it remains a valuable screening tool and stress the study does not mean people should avoid having colonoscopies.

"This is a darn good test, but it's not perfect," said Dr. David Ransohoff, a gastroenterologist and professor of medicine at the University of North Carolina, Chapel Hill.

Doctors often tell patients a colonoscopy can trim the risk of dying from colon cancer by 90 per cent. But Ransohoff said the new data suggests closer to 60 or 70 per cent.

"The findings of zero protection for the right colon is so different than what we expected, it just grabs you by the lapel," he said. "What it means for the profession is we need to step back and think: `What evidence do we have for the effectiveness of colonoscopy?'"

The Ontario-wide study looked at more than 10,000 people diagnosed with colon cancer between 1996 and 2001, and who had died of the disease by 2003. Researchers then matched each patient with five other similar individuals who did not die of colon cancer. By comparing the two groups, they were able to evaluate the effectiveness and limitations of colonoscopy.

A colonoscopy is used to detect and remove polyps, the small growths on the inner surface of the colon which can turn cancerous. Colorectal cancer is the second leading cause of cancer death in Canada, and is 90 per cent curable if detected early enough.

Dr. Nancy Baxter, the study's lead author and scientist at the Li Ka Shing Knowledge Institute at St. Michael's Hospital, said colonoscopy is still one of the most effective cancer detection tests available."

*****************
Comment on this article by:

(cut and paste): http://www.thedoctorschannel.com/video/1225.html

"....In an accompanying editorial, Dr. David F. Ransohoff, from the University of North Carolina, Chapel Hill, discusses several possible explanations for the findings -- including the possibility that colonoscopies listed as complete did not actually reach the cecum, or that colon preparation was inadequate, or that right-sided lesions tend to grow more rapidly and arise between screenings.

Overall, Dr. Ransohoff concludes, "Colonoscopy is an effective intervention, but as Baxter and colleagues suggest, we must realize that current evidence is indirect and does not support a claim of 90% effectiveness."

He adds that "until we have better data, we can be grateful and optimistic to have a useful intervention to offer our patients, but we should be realistic and cautious when talking with them about the magnitude of both benefits and risks."

Reference:
Ann Intern Med 2009;150. ...."


Toronto Star

My e mail reply to any employee of the NC DOI is sent back as undeliverable: writing the Commissioner, Jiim Long

Marsha V. Hammond, PhD Clinical Licensed Psychologist, NC
E mail: hammondmv@netzero.com fax: 828------------
Cell phone: 404 964 5338

RE:

I received the following reply from Ms. Thornton at your office, the DOI; I tried to e mail her back but my e mail is rejected. I tried to report the rejection to the ITS department and THAT was rejected.

Here is the issue: (first here is the letter from your employee, Ms. Thornton):

"Dr. Hammond:
I have been reviewing the information you were previously given by Ms. Edwine with other Divisions within our Department to ensure proper information was relayed to you regarding your concerns with BCBS. The information you have been given was correct and I hope this further explanation helps.
NCGS 58-3-179 requires a health plan to provide coverage for colorectal cancer screening with the same deductibles, coinsurance and limitations as apply to other services covered under the plan. There is nothing in the law that addresses where the colorectal screening must take place in order to be covered under a health plan.
The NC Department of Insurance is limited to ensuring the company complies with the provisions of its policy contracts as well as complies with relevant insurance statutes and regulations that have been enacted by our Legislature. We do not have the authority to require BCBS provide benefits above and beyond that which is stated in the contract.
Thank you for the opportunity to respond further to you.
Becky P. Thornton, AIRC, ACS, HIA, MHP
Life and Health Supervisor
Consumer Services Division"

*********************

Here, from your own department’s website, is the statement about coverage of colorectal screening:

http://www.ncdoi.com/LH/News/Documents/HMOBasicAndStandardPlans_MentalHealthUpdate.pdf

EVERY STANDARD HEALTH BENEFIT PLAN THAT IS DELIVERED, ISSUED
FOR DELIVERY, OR RENEWED ON OR AFTER JANUARY 1, 2002 SHALL
PROVIDE COVERAGE FOR COLORECTAL CANCER EXAMINATIONS AND
LABORATORY TESTS. THIS COVERAGE SHALL BE AT LEAST EQUAL TO
THE COVERAGE REQUIRED BY NCGS 58-3-179.

****************

Here is my reply to Ms. Thornton’s letter and I submitted this also at your website, specifically: http://www.ncdoi.com/Consumer/Complaint.asp

“In my e mail letter which was rejected, this is what I said and this is the kernel of my complaint here---to which I would like a reply:

"I am not asking the NC Department of Insurance to demand that BCBSNC exceed the terms of the agreement in place as per my family's coverage. I am asking that the NC Department of Insurance attend to the law which you sited which states that there be adequate network availability. And there is NOT network availability for screening colonoscopies which are covered, by law. There are no screening colonoscopies that are reimbursed by BCBSNC PPO within two hours of Asheville, NC, a major metropolis.

I have a standard policy. There is a $2500 deductible for INPATIENT services. I understand that. There is a gastroenterologist in Boone, NC, apparently, who offers an 'OFFICE BASED' screening colonscopy who is part of the BCBSNC network. This is over two hours away from Asheville, NC, a major metropolis w/ a number of gastroenterology services. There are no other colonoscopies in western NC, other than CLINIC BASED, which is defined by BCBSNC as INPATIENT, available in western NC.

If the service is demanded by law to be covered by an insurance company, and if the insurance company avoids offering the coverage as per its policy---by placing the by-law covered service----then why don't one of two things take place?

1. BCBSNC creates a relationship w/ other gastroenterologists in western NC, something they told me over a year ago they were intent on doing----BUT HAVE NOT
2. BCBSNC pay for the by-law covered service within a reasonable distance to the major metropolis?

I would like to know if the NC Department of Insurance is going to attend to the law which requires BCBSNC---- as associated with NCGS 58-3-179 in terms of 'providing coverage for colorectal cancer examinations which is at least equal to the coverage required by NCGS 58-3-17', which is associated with the notion, Network Adequacy---to provide coverage for policy-holders.

You indicated that there is nothing in the law that attends to WHERE the procedure is to be obtained. However, the law does specify that specialty services must be covered in a manner 'at least equal' to other coverage. "

THANK YOU AND I AM LOOKING FORWARD TO YOUR RESPONSE.
cc: Representative Susan Fisher”

NC Department of Insurance provides coverage to BCBSNC for not making accessible screening colonscopies as per NCGS 58-3-179

Marsha V. Hammond, PhD: Licensed Psychologist: NC
fax: 828 ---------e mail: hammondmv@netzero.com http://madamedefarge2scutinizingbcbsnc.blogspot.com/

RE: BCBSNC policy which does not cover screening colonoscopies as they are not available in western NC

December 12, 2008

Dear Ms. Thornton (Becky P. Thornton, AIRC, ACS, HIA, MHP
Life and Health Supervisor Consumer Services Division: "Becky Thornton" ) and Luann Muntz (Luann Muntz Clinical Review Analyst
Healthcare Review Program (919) 807-6863 Lrmuntz@ncdoi.net), of the NC Department of Insurance:

Thank you for your e mail letters regarding my concern about the lack of BCBSNC PPO coverage in western NC as per screening colonoscopies. (I enclose a copy of that below under 'item 1').

I am not asking the NC Department of Insurance to demand that BCBSNC exceed the terms of the agreement in place as per my family's coverage. I am asking that the NC Department of Insurance attend to the law which you sited which states that there be adequate network avaibility. And there is NOT network availability for screening colonoscopies which are covered, by law. There are no screening colonoscopies that are reimbursed by BCBSNC PPO within two hours of Asheville, NC, a major metropolis.

I would like to know if the NC Department of Insurance is going to attend to the law which requires BCBSNC---- as associated with NCGS 58-3-179 in terms of 'providing coverage for colorectal cancer examinations which is at least equal to the coverage required by NCGS 58-3-17', which is associated with the notion, Network Adequacy---to provide coverage for policy-holders.

You indicated that there is nothing in the law that attends to WHERE the procedure is to be obtained. However, the law does specify that speciality services must be covered in a manner 'at least equal' to other coverage.

And so as pertaining to the matter of 'as apply to other services covered under the plan', I might speculate that if I had to travel over 2 hours to go to my son's pedicatrician, that would be not in keeping w/ the plan, would it? Or if I had to go to a gynecologist over two hours away, that would not be in keeping w/ the plan, would it? And so, in keeping w/ other services which do not require a two hour trip, I believe that the answer is that BCBSNC must have a provider who can make available the screening colonoscopy service.

My understanding is that the law has to attend to the 'network availability' and there are no screening colonoscopies to be had in western NC except in Boone, NC, where there is an 'office based' screening colonscopy-----which is all that BCBSNC PPO will pay for. (see Item 2 below).

I noted this at the law's site, the number which you indicated to me in your e mail, specifically:

(per google):

[PDF]

1 NORTH CAROLINA’S SMALL EMPLOYER GROUP BASIC AND STANDARD HMO ...
File Format: PDF/Adobe Acrobat - View as HTML
THE COVERAGE REQUIRED BY NCGS 58-3-179. EVERY STANDARD HEALTH BENEFIT PLAN THAT IS DELIVERED, ISSUED. FOR DELIVERY, OR RENEWED ON OR AFTER JANUARY 1, ...
www.ncdoi.com/LH/News/Documents/HMOBasicAndStandardPlans_MentalHealthUpdate.pdf - Similar pages -
http://www.ncdoi.com/LH/News/Documents/HMOBasicAndStandardPlans_MentalHealthUpdate.pdf

NORTH CAROLINA’S SMALL EMPLOYER GROUP BASIC AND STANDARD HMO HEALTH BENEFIT PLANS BENEFITS AND EXCLUSIONS

"EVERY STANDARD HEALTH BENEFIT PLAN THAT IS DELIVERED, ISSUED FOR DELIVERY, OR RENEWED ON OR AFTER JANUARY 1, 2002 SHALL PROVIDE COVERAGE FOR COLORECTAL CANCER EXAMINATIONS AND LABORATORY TESTS. THIS COVERAGE SHALL BE AT LEAST EQUAL TO THE COVERAGE REQUIRED BY NCGS 58-3-179."

*************************

I would like to hear from you or someone at the NC Department of Insurance about this matter which surely impacts thousands of NC citizens.

In accord w/ Ms. Rudd-Muntz's suggestion, I have filed a complaint. I would like to know what happens to those complaints. Thank you for letting me know. Please feel free to pass this e mail to any pertinent party.

Sincerely,

Marsha V. Hammond, PhD

*************************

Item 1: your letter re: my letter to you as pertaining to this matter:

Dr. Hammond:
I have been reviewing the information you were previously given by Ms. Edwine with other Divisions within our Department to ensure proper information was relayed to you regarding your concerns with BCBS. The information you have been given was correct and I hope this further explanation helps.
NCGS 58-3-179 requires a health plan to provide coverage for colorectal cancer screening with the same deductibles, coinsurance and limitations as apply to other services covered under the plan. There is nothing in the law that addresses where the colorectal screening must take place in order to be covered under a health plan.
The NC Department of Insurance is limited to ensuring the company complies with the provisions of its policy contracts as well as complies with relevant insurance statutes and regulations that have been enacted by our Legislature. We do not have the authority to require BCBS provide benefits above and beyond that which is stated in the contract.
Thank you for the opportunity to respond further to you.

Becky P. Thornton, AIRC, ACS, HIA, MHP
Life and Health Supervisor
Consumer Services Division





--------------------------------------------------------------------------------
From: Luann Rudd-Muntz
Sent: Thursday, December 11, 2008 8:21 AM
To: hammondmv@netzero.net
Cc: Becky Thornton; Doris Edwine
Subject: RE: Possibly spam: req to investigate BCBSNC no screening colonoscopies available in west ern NC


Dr. Hammond,

The Healthcare Review Program assists consumers who have been denied payment of medically necessary benefits by their insurers.

The Consumer Services Division can best address your concern, and investigate your complaint. I have forwarded your e-mail to them. Consumer Services can be reached at 800-546-5664 .

You may also complete a consumer complaint on the web-site at www.ncdoi.com. by selecting the first bullet in the center column, you will be taken to the information you'll need to complete the complaint.

Sincerely,

Luann Muntz
Clinical Review Analyst
Healthcare Review Program
(919) 807-6863
Lrmuntz@ncdoi.net

*************************
Item 2:
[PDF]

C 24 ONSUMER ROTECTIONS
File Format: PDF/Adobe Acrobat - View as HTML
There are special consumer protections built into the laws governing small-group ...... [N.C.G.S. §§ 58-3-179, 58-50-155]. Contraceptives ...
www.nciom.org/hlthinspgms/C24.pdf - Similar pages -

http://www.nciom.org/hlthinspgms/C24.pdf

Network Adequacy

Insurers that operate network-based plans (like HMOs or PPOs) must have systems to ensure the adequacy of the network. Insurers must set their own access standards and monitor how well the network meets these internal standards. The health plan’s access standards should include information about how long enrolees must travel to obtain primary care, specialty care, hospital-based services and other facilities."

With no answers from Rep Fisher or someone in the Department of Insurance, asking for f/u by External Reviewers of NC Department of Insurance

Marsha V. Hammond, PhD e mail: hammondmv@netzero.com cell: 404 964 5338 BCBSNC PPO policy-holder NC Department of Insurance case number: : 2008-10-01135

December 11, 2008

Hello NC Department of Insurance, External Review Department: (snestor@ncdoi.net,kshortt@ncdoi.net,lrmuntz@ncdoi.net,cmckoy@ncdoi.net)

Can you find out why the below is taking place and how I can get to a clinic based screening colonoscopy----which is what gastroenterologists offer? They cost about $1200.00, are to be had, unless one has polyps, every 10 years, are preventive, and BCBSNC will not cover a clinic based screening colonoscopy.

Specifically, I, my husband, and 14 yr old son, all in good health, have BCBSNC PPO. It is time for me to have a screening colonoscopy. I have bought my complaint to someone in the Department of Insurance, specifically, Doris Edwine, tel 919 807 6773. I wrote her a letter outlining these matters. She was presented by BCBSNC, I guess, w/ a list of gastroenterologists in western NC---none of whom will do a screening colonoscopy as a office visit----which is what BCBSNC will pay for. And so there are no screening colonoscopies available tho BCBSNC is (appropriately) sending me a letter stating that I should have one!

Can someone help me w/ this? I have asked my representative, Susan Fisher. I get no reply. The Department of Insurance has assigned me a number but nothing is taken care of.

I have been investigating this for over a year now.

Imagine all the people w/ these policies who will come down w/ colon cancer just in time for Medicare to pick it up. It will have been/ could have been so prevented by early detection.

Pass this e mail to any pertinent party. You can see a compendium of my attempts to get this service here where you can see that I have repeatedly contacted BCBSNC government liasons. http://madamedefarge2scutinizingbcbsnc.blogspot.com/

Sincerely, Marsha V. Hammond, PhD

*********************************

This is what I have sent to my representative, Susan Fisher:

hammondmv@netzero.com

Monday, November 24, 2008
Dear Rep Fisher: Insurance Commissioner’s office cannot get past lies of BCBSNC PPO re: non-availability of colonoscopies in western NC

Letter to Representative Susan Fisher: Fisherla@ncleg.net

Marsha V. Hammond, PhD: Clinical Licensed Psychologist, Asheville/ Waynesville, NC

e mail: hammondmv@netzero.com cell: 404 964 5338

RE: NC Department of INsurance cannot see past the song & dance of BCBSNC re: screening colonoscopies

November 24, 2008

Dear Susan Fisher, my NC House of Representatives person:

There are still no screening colonoscopies for citizens of western NC w/ BCBSNC insurance plans….2.5 million of us across the state. Most lately, the NC Department of Insurance has fallen for their song and dance which seems to be associated with coverage, but in fact, is not.

To make it all the more hilarious, BCBSNC just sent me a letter suggesting that I have a screening colonoscopy!

I talked to the insurance commissioner’s office, specifically, Doris Edwine, tel 919 807 6773. I wrote her a letter.

BCBSNC simply sent her a list of the gastroenterologists in Buncombe county. As I have done before, I called them. They told me what they have told me before, namely that their practices will not do office based screening colonoscopies. They do only clinic based screening colonoscopies…like they told me a year ago.

I have been researching this for a year now (please see the blog which does not reflect the six months prior to the first post in June, 2008). Nothing has changed. I would like to know what the NC State Legislature which oversees BCBSNC is going to do about this.

BCBSNC PPO will not pay for clinic based screening colonoscopies and the gastroenterologists will not do the office based ones, I assume, as associated w/ the risk of having a patient move around on the table and then puncturing their colon which means that —literally—-you better have created your will cause you’re a dead person.

My file number: 2008-10-01135.

It would be useful to have my NC State Representative check on this matter, I believe.

Thank you.

Marsha V. Hammond, PhD

NC State Legislature gives up on monitoring NC BCBS: 'Get a new home please'

NC Spin: http://www.ncspin.com/

"....The State Health Plan will be a subject of discussion in this legislative
session. Most all agree the Health Plan needs to find a new home, that the
legislature is neither qualified nor able to adequately oversee and administer
the plan that is now considered to have a projected $500 million shortfall. ..."