This Week – February 23, 2013

This Week in Washington DC:

  1. Private Insurers Must Waive Cost-Sharing for Removing Polyps During Screening Colonoscopy
    Beginning 2014
  2. Congress Seeks ACG’s Feedback on Medicare Reimbursement Reform

HHS and DOL Release Guidance for Private Insurers: No Patient Cost-Sharing for Therapeutic Colonoscopy
On Wednesday, February 20th, the U.S. Department of Health and Human Services (HHS), the Department of Labor (DOL), and Treasury released guidance on preventive services, and other “essential health benefits,” private insurers must adhere to beginning January 2014. The guidance is pursuant to the Patient Protection and Affordable Care Act (now known as the “ACA”), which requires HHS to set forth coverage determinations and help establish “health-insurance exchanges” in each state. The guidance also applies to states choosing to administer their own exchange as well as those deciding to let the Federal Government run the exchange. While each state was given the option to run their exchange, as of today, 26 states have informed HHS that they will default to the Federal Government.

Please see the excerpt from the Guidance here:


Q5: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the USPSTF recommendation, is it permissible for a plan or issuer to impose cost-sharing for the cost of a polyp removal during the colonoscopy?

No. Based on clinical practice and comments received from the American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and the Society for Gastroenterology Nurses and Associates, polyp removal is an integral part of a colonoscopy. Accordingly, the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure. On the other hand, a plan or issuer may impose cost-sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.

ACG appreciates the Obama Administration’s efforts to remove these barriers to increasing colorectal cancer screening utilization rates. ACG has fought for over a decade to remove cost-sharing for colorectal cancer screening in Medicare as well as in the private insurance market since the ACA was passed in 2010. Both provisions were incorporated in ACG’s signature legislation the “SCREEN Act” last Congress. The other GI societies as well as the American Cancer Society, Fight Colorectal Cancer, the National Colorectal Cancer Roundtable, the Digestive Disease National Coalition, and other organizations are engaged in these issues as well.

However, cost-sharing still applies in Medicare when screenings turn therapeutic. Thus, ACG will continue to support any legislation removing Medicare beneficiary cost-sharing when polyps are removed during screening exams.

Congressional Staff Seeks ACG Recommendations on Reforming Medicare Reimbursement
ACG was recently invited to meet with congressional committee staff from the House of Representatives Committees on Ways & Means and Energy & Commerce to discuss repealing the sustainable growth rate (SGR) formula and reforming the Medicare reimbursement system. Committee staff requested feedback from ACG and other attendees on how to incorporate quality initiatives developed by the specialty societies into Medicare reimbursement.

ACG believes that if Congress chooses to repeal SGR with a reimbursement system based on quality reporting, specialty societies should be looked to when defining what is considered “quality of care.” These measures will be more clinically meaningful and will improve patient outcomes. Congress must also ease the practice-management burdens due to the various quality reporting programs required in Medicare, and instead, allow participation in other initiatives, such as the GI Quality Improvement Consortium (GIQuIC), to satisfy these various mandates. Lastly, ACG maintains that the provider should be adequately paid and rewarded for demonstrating a high quality of care as measured by any aligned specialty society-Medicare quality reporting initiative. These principles, together with removing patient barriers to colorectal cancer screening as mentioned above, were also incorporated in the SCREEN Act last Congress.   

ACG is encouraged by the interest to repeal SGR in the 113th Congress and appreciates being part of this discussion to reform the Medicare reimbursement system. We will continue to be your voice on Capitol Hill and represent clinical gastroenterology during these discussions.

Please stay tuned for further updates. Please also share and discuss your thoughts with fellow ACG members on the ACG GI Circle. To login and share your comments, go to and sign in as a member. Once you have done so, click here and then click the orange "Visit ACG GI Circle" button to be taken to the GI Circle site. If you have not yet activated your ACG GI Circle account, please email us at

Contact Brad Conway, VP Public Policy, with any questions or for more information.

Brad Conway