Georgia DOI issues directive on preventive colorectal screenings

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Georgia Insurance Commissioner Ralph Hudgens has issued a directive that addresses in-network preventive care services (in the context of the Affordable Care Act) that says that “all services directly related to a preventive colonoscopy, including an associated facility, anesthesia, pathology, polyp removal, physician fees, and pre-operative examination and consultation, are to be provided with no member, subscriber or insured cost sharing.”
 
Medical Association of Georgia Legal Analyst Kimberly Ramseur explains that, “[According to the directive] In instances where claims are not properly coded or adjudicated correctly, it is the insurer’s duty to adjust the claim promptly, fairly and accurately once it becomes known that the claim is attributed to a preventive colonoscopy screening. Coding issues, will not be a sufficient reason for an insurer not to adjudicate the claim correctly and adjust cost sharing once issues are made known. [And] Any insurers that fail to take action and make the requisite adjustments in a timely fashion will be viewed taking part in unfair claims settlement practices.”
 
Ramseur also notes that the directive states, “Insurers must also develop guidelines in electronic or printed format to disseminate to all insureds, members or subscribers information. Such guidelines will include, but are not limited to explanations of the differences between diagnostic and preventive, cost sharing and no cost sharing, in or out-of-network, helpful hints or other forms of guidance and reasonable expectations regarding referrals for preventive colorectal screenings.”
 
Finally, she says the directive applies to “any comprehensive, major medical individual or group insurance plan, policy or contract for health care services issued, delivered, issued for delivery, executed or renewed by an insurer in this state. It excludes the following limited benefit insurance policies: accident only, CHAMPUS supplement, dental, disability income, fixed indemnity, long-term care, Medicaid, Medicare supplement, specified disease, vision, self-insured plans, and nonrenewable individual policies written for a period of less than six months.”
 
MAG members can contact Ramseur at kramseur@mag.org or 678.303.9274 with questions.
 
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