Insights

Insurance Directive Reinforces No Cost Sharing Related to Preventive Colonoscopy


On Nov. 2, 2016, Commissioner of Insurance Hudgens issued Directive 16-EX-6 to all Georgia insurers related to in-network preventive colorectal screenings. CMS and other federal agencies have provided sufficient guidance to establish that all services directly related to a preventive colonoscopy are to be provided without cost sharing. The actual findings of the screening have no bearing on the cost sharing. Yet, it has come to the Commissioner’s attention that issues continue to occur as to the breadth of coverage including improper cost sharing, denials of claims, or improper balance billing.

This directive clarifies that it is the insurer’s responsibility to adjust the claim promptly, fairly and accurately once it is determined that the claim is related to the preventive colonoscopy screening. Failure of insurers to make proper adjustments in a timely manner will be viewed as unfair claims settlement practices.

Insurers are also tasked with developing educational materials for insureds highlighting different concepts that include (but are not limited to) the differences between diagnostic and preventive, cost sharing and no cost sharing, in or out-of-network, and providing helpful guidance regarding referrals for preventive colorectal screenings.

Although this directive is aimed at insurers, it is important for employers to be aware of what insurers may be doing and what they are now directed to do.

Directive 16-EX-6 »