Friday, December 28, 2007

ZEN KOAN 4 2008: What do a colonoscopy and mental health care have in common?: LACK OF COVERAGE

FROM: Marsha V. Hammond & Anthony V. Jones : Asheville, NC

TO: BCBSNC Appeals Process PO Box 30055 Durham, NC 27702-3055

RE: no office visit colonoscopy services available in Western NC under any BCBSNC plan

December 28. 2007


Thank you for making available health insurance for our family. We have paid your company approximately $50,000 over the past 7-8 years.

We have needed no major surgeries and have therefore spent, inclusive of outpt visits, emergency care offices, and medication, less than $5000 as associated with that payment into your system.

I realize that this is not the way that things are ‘figured.’ Your representative with whom I spoke on December 28, 2007, whom was very helpful, stated: “No provider chooses to offer office based colonoscopies” in Western NC. She was not able to uncover ANY physician’s office that would offer an office based colonoscopy in one-fifth of the state of NC.

This is what I note to be taking place from my perspective: BCBSNC is not adhering to best practices and medical necessity regarding a critically important screening device. Providers are not offering office based colonoscopies as it is not best practices.

**Why is a screening colonoscopy important?

“Colorectal cancer is the third leading cause of cancer deaths in the United States, and the risk for it increases with age. Patients with colon cancer rarely display any symptoms, and the cancer can progress unnoticed and untreated until it becomes fatal. Fortunately, colorectal cancer can be prevented if diagnosed and treated early.”

**Why is clinic based colonoscopy stated to be best practices by medical providers?

“Colonoscopy.Those patients who had effective analgesia during their procedures and reported less discomfort were much more likely to agree to come back on a 10-year basis, which is what is recommended. "If you hurt people too much, they just won't think it's worth it to come back," Romeo explains.” HealthCare Benchmarks and Quality Improvement, March, 2003 :

I have been trying to obtain this service for sometime. In speaking w/ one of your representatives in September, 2007, he advised me there was one provider in Henderson county, 50 miles from Asheville, who provided office based colonoscopies. I called that office several times. No one answered and no one returned my calls. I just cannot believe, in this litigious day, that your company does not want to make available such a critically important screener. Should I get into my car, drive 100 miles round trip to Hendersonville in order to simply make an appointment for an office based colonoscopy, wait for a number of months, undergo a painful critical procedure which is not best practices? This is not acceptable

Here is the problem in a nutshell: BCBSNC will only pay for an office visit colonoscopy. Office visit colonoscopies are not available. Why aren’t they available? Because they are not best practices any longer and have not been for probably 15 years. Why aren’t office based colonoscopies available any longer? Because GI physicians understand that people do not willingly submit to un-medicated, painful procedures. Clinic based colonoscopies is what is available---across the board. In a clinic, one gets an IV, medication, and a fiberoptic scope inserted into one’s rear. In office, one gets a fiberoptic scope inserted into one’s rear and no medication.

Why won’t BCBSNC therefore pay for clinic based colonoscopies which is associated with giving the patient something to ease the procedure? Are you trying to save this money in order to take BCBSNC taxpayers’ assets and turn it into corporate assets, making a power money grab off the backs of consumers like myself and my husband?

No BCBSNC plan (A,B, or C) makes accommodation at any level of deduction for any best practices, clinic-based colonoscopy procedure. You either pay the $1300 out of pocket for this (only availability) clinic-based, critical procedure----or you don’t get it. I cannot imagine that the cost of treating colon cancer is cheaper than the offering of this medically necessary, best practices, procedure.

This letter it therefore a request to make available to my husband and myself, as associated with our BCBSNC Plan A, both 53 years old, a screening colonoscopy that is clinic based for the year 2008.

Thank you for letting me know about your decision.


Marsha V. Hammond, PhD Anthony V. Jones, MA

cc: BCBSNC CEO Bob Greczyn, president and CEO, BCBSNC
Dr. Don Bradley, chief medical officer, BCBSNC
Blue Cross and Blue Shield of North Carolina P.O. Box 2291Durham, NC 27702

Health and Insurance NC State Legislature:,,,,,,,,,,


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