Colonoscopy and Insurance Payment

[Packman]

I had a colonoscopy last year and the doc found one small polyp. It was removed and benign. Doc suggested another colonoscopy in one year as I have cancer history in the family. The procedure is scheduled for November. I am trying to verify that ACA insurance will pay for this procedure. I called the gastro doc's office and they don't seem to know, but said that once a polyp is found, it is no longer considered a "screening" so insurance may not pay. I thought all "preventative" colonoscopies were paid by insurance.

First question - is one year between procedures too conservative? Second, is it true that once a polyp is found, that all future colonoscopies are patient pay?

 

[gauss]

I wonder if the fact that the polyp was benign influences the future classification?

We have a somewhat similar situation in that DW screening mammogram indicated the need for further detailed mammogram and ultrasound. It all came back all clear, but will this be an issue going forward? And yes, insurance does seem to be charging the deductible for the detailed mammogram and ultrasound in that they appear not to be considered routine screening.

 

[Fedup]

I don’t believe so. My sister has ACA insurance from California and she has a few already. She did have precancerous polyps so she had to have a bit more frequent than mine, but not in one year. But she had to pay her copays.

 

[joeea]

but said that once a polyp is found, it is no longer considered a "screening" so insurance may not pay. I thought all "preventative" colonoscopies were paid by insurance.

I think they were trying to tell you that since it is no longer a "screening" it won't be considered "preventative". The best way to find out for sure is to talk to your insurance company.

Second, is it true that once a polyp is found, that all future colonoscopies are patient pay?

Not on my dad's insurance policy. He has had polyps removed and hasn't had to pay for subsequent colonoscopies. But he wasn't told to get a repeat at 1 year either.

 

[bingybear]

To find out if insurance will pay, talk to your insurance.

Before ACA I had a colonoscopy and they found one pre-cancerous. My PCP said if they left it in it would not become cancer after 10 years.

But the insurance company changed it from routine to diagnostic... thus I had to pay for the colonoscopy and biopsy. Since then I've been getting checked every 5 years with nothing found yet since the first one.

So I expect you will get to pay for it.

Medicare has a different standard for what is done as routine/well check. So things may change at that time.

The ACA may have changed what is routine vs diagnostic since my tests.



I would ask your doctor about the 1 year retest. There could have been other things they saw with you or something in your history.

edit - I looked at my ACA plan, looks like it may be covered YMMV

 

[Teacher Terry]

Everyone else I know with polyps only get one every 5 years. They grow slowly.

 

[savory]

The suggestion to speak to your insurance company is a good one.

Here is what happened to me. A polyp was found in a previous exam. It was benign. I was not as wise as you to ask the questions you are asking here. On the form given to me prior to the procedure, I checked the 'polyp found box' in previous exam. The exam was no longer a screening. I ended up paying about $3,000 after thinking it would be covered as a screening exam.

I did a lot of post research and learned I should have done better research upfront. Unless something has changed and I do not think it has, you are on longer in the 'screening' category. So, check your insurance for what they cover.

Having said all this, perhaps your doctor is being cautious and/or maybe there is another procedure/test that is pretty good. I do not know that, just a suggestion to investigate an alternative approach to the colonoscopy.

 

[bingybear]

Everyone else I know with polyps only get one every 5 years. They grow slowly.

5 years is common. I know some that get them more often, even 2 years. I do know one who likely gets it yearly. He is my son's age and has had colon cancer twice.

That is what made me question what else was seen in the OP's case if only one benign poly was found.

 

[Bamaman]

Sometimes a call from the doctor can get such a procedure approved. Most often after age 50, colonoscopies are 5 year routine procedures.

 

[Fedup]

There are a few types of polyps, I know my sister had something more serious than mine.

 

[Texas Proud]

Just pure memory and from reading, so it is worth almost nothing...


IIRC, the medical prof says a colonoscopy every 10 years... so anything shorter than that is not preventive... you would have to pay...



Now, the question then becomes how much? On other threads the price has been anywhere from $800 to over $2500...

 

[NoMoreJob]

My understanding is that there are different types of polyps. When a polyp or polyps are removed they are tested and typed. If they are the type(s) that may become cancer (precancerous) then the recommended amount of time before your next colonoscopy will be about 3 years. If there are polyps but they are not precancerous then the time frame will be about 5 years and if there are no polyps then the time frame is typically 10 years.

My first colonoscopy the age of 52 found no polyps, was paid for under my private medical policy (prior to ACA) as preventative at it was recommended that my next procedure be in ten years. My second at the age of 62 found 3 precancerous polyps, the entire procedure was paid for under my ACA policy and it was recommended that I have another in 3 years. My third was done at the age of 66 (a year later than recommended) and 5 precancerous polyps were found, the procedure was 100% covered under traditional Medicare + G Supplement.

My understanding is that if the procedures can be shown to be medically justified then they are going to be paid for one way or the other. Generally a procedure is justified every ten years if nothing is found. If polyps are present then the type of polyp(s) determine how often follow-ups are justified.

In case there are questions from insurers I always keep the report from my previous colonoscopy. The report contains the detail of what was done, what was found and, based on that information, when my next procedure is recommended. If that recommendation is followed I would expect it to be covered by either an ACA policy or Medicare. I don't know what the rules or coverage might be for other types of policies such as short-term medical or cost sharing plans.

 

[bingybear]

I took the OP to mean that the procedure would be completely covered, not subject to deductible. I would agree that it would be covered subject to deductible if medically necessary. My first 2 were covered subject to deductible as something was found on the first one.Both of my tests may have been under employer plans.

 

[nap470]

I had a colonoscopy last year and the doc found one small polyp. It was removed and benign. Doc suggested another colonoscopy in one year as I have cancer history in the family. The procedure is scheduled for November. I am trying to verify that ACA insurance will pay for this procedure. I called the gastro doc's office and they don't seem to know, but said that once a polyp is found, it is no longer considered a "screening" so insurance may not pay. I thought all "preventative" colonoscopies were paid by insurance.



First question - is one year between procedures too conservative? Second, is it true that once a polyp is found, that all future colonoscopies are patient pay?

I recently had my second colonoscopy at the 5 year point due to the doctor finding a benign polyp at the first one. I made the mistake of assuming since the doctor scheduled it at 5 years that it was covered. After the procedure, my Blue Cross PPO would not cover it. They said less than 10 years was considered a screening and not preventative. Since the doctor found another benign one this time also, I know I will be paying for it again in 5 years. I have a family history of cancer and polyps, so I'm not taking chances.

 

[JoeWras]

A good GI practice will verify with the insurance carrier what is and what is not covered before you have the procedure.

I had high deductible plan and not had to pay anything out of pocket for the first screening, and subsequent recommended follow ups due to polyp finds.

 

[Turbo29]

Three colonoscopies:


52yo -- 2 polyps removed; come back in 5yr.
57yo -- no polyps; come back in 5yr (This colonoscopy not considered preventive).
62yo -- no polyps; interval extended to 10yr (Don't know if the colonoscopy in 10yr will be considered preventive).

 

[Dtail]

Three colonoscopies:


52yo -- 2 polyps removed; come back in 5yr.
57yo -- no polyps; come back in 5yr (This colonoscopy not considered preventive).
62yo -- no polyps; interval extended to 10yr (Don't know if the colonoscopy in 10yr will be considered preventive).

Shouldn't matter, as you will be on Medicare then.
BTW, now that's some first post.

 

[Fedup]

I’ve heard once you hit 70, colonoscopy is not as useful. Is this true?

 

[audreyh1]

My understanding is that there are different types of polyps. When a polyp or polyps are removed they are tested and typed. If they are the type(s) that may become cancer (precancerous) then the recommended amount of time before your next colonoscopy will be about 3 years. If there are polyps but they are not precancerous then the time frame will be about 5 years and if there are no polyps then the time frame is typically 10 years.

My DH had a polyp removed. It turned out to be muscle fibers that would never ever develop into cancer, so he’s back on the normal screening timeline.

 

[gayl]

I'm editing this to remove too personal info: leaving only that some HMOs have no issue with covering annual colonoscopies as they would rather catch issues before chemo is necessary.

 

[Helena]

.

Like everything else, heath insurance claims are processed by computer. The doctor's office files the claim with diagnosis and procedure codes. Those codes alone usually determine whether a claim is paid as preventive or regular medical. However some preventive care codes might be subject to time restrictions per the policy.

.

 

[Smitty700]

I’ve heard once you hit 70, colonoscopy is not as useful. Is this true?

It is not about being useful. It's more about questions if the risks of the colonoscopy procedure in older patients outweigh the benefits. Here's an article from Scientific American from a few years ago: https://www.scientificamerican.com/article/many-colonoscopies-for-seniors-carry-unnecessary-risks/