Migliaccio & Rathod LLP is investigating whether certain employer health plans improperly charged patients deductibles, copayments, or coinsurance for preventive care medical services that should have been covered without cost-sharing.
We are particularly interested in two situations.
First, some patients receive an at-home or laboratory colorectal-cancer screening test, such as a FIT test or Cologuard. If that test is positive, the patient’s doctor may order a follow-up colonoscopy. In many employer health plans, that follow-up colonoscopy is part of the preventive screening process and should be covered without patient cost-sharing. Nevertheless, some patients may have been charged because the procedure—or part of the procedure—was incorrectly processed as “diagnostic.”
Second, we are investigating charges imposed on patients taking HIV pre-exposure prophylaxis, commonly known as PrEP, including charges for qualifying medications and associated preventive testing or monitoring that should have been covered without cost-sharing.
You May Be Affected If:
- You receive health insurance through your private-sector employer, or through a spouse’s or parent’s private-sector employer;
- You had a colonoscopy after receiving a positive FIT, Cologuard, or other qualifying colorectal-cancer screening test and were charged a deductible, copayment, or coinsurance;
- You underwent a screening colonoscopy and were charged additional amounts because a polyp was found or removed;
- You were charged separately for anesthesia or other services associated with a qualifying preventive colonoscopy;
- You use PrEP and were charged a deductible, copayment, or coinsurance for qualifying PrEP medication, laboratory testing, or related preventive services; or
- Your Explanation of Benefits shows patient responsibility for one of these preventive services.
Does This Apply to Your Health Plan?
This investigation generally concerns people enrolled in employer health plans governed by ERISA. In everyday terms, this usually means health coverage obtained through a private-sector employer, including coverage obtained through your spouse’s or parent’s private-sector job.
Both self-funded plans and plans insured through an insurance company may qualify.
Government employee plans and certain church plans generally are not governed by ERISA. Some older “grandfathered” health plans may also be subject to different preventive-care requirements.
If you are unsure what kind of plan you have, we can review your insurance card, Explanation of Benefits, Summary Plan Description, or other benefits documents.
We Are Interested in Hearing From Patients Who:
- paid out of pocket for a follow-up colonoscopy after a positive stool-based screening test;
- were charged after a polyp was found or removed during a screening colonoscopy;
- were billed separately for anesthesia or facility charges tied to a preventive colonoscopy;
- paid for PrEP medication that they expected to be covered without cost-sharing;
- were charged for PrEP-related lab work, testing, or monitoring;
- appealed a preventive-care charge but did not receive a refund; or
- have EOBs, bills, receipts, or plan documents showing the charges.
If you believe your employer-sponsored health plan charged you for preventive care services that should have been covered without cost-sharing, we would like to hear from you. Please complete the contact form on this page, send us an email at [email protected], or call us at (202) 470-3520.