Preventative Colonoscopy Shock

[MBSC]

My DH, 60 yrs old, signed up for a colonoscopy. Since it's a preventative there's no cost to us, or so we thought. I started reading articles where people had the preventative colonoscopy. They found benign polyps and were charged for diagnostic colonoscopy, big difference!

This was common on non-Medicare claims before the ACA. For a screening colonoscopy under the ACA, the provider now bills modifier 33 with the procedure code to prevent cost sharing.

If the provider forgets to bill the modifier and cost sharing is applied, the provider submits a 'corrected claim' with the modifier and the cost share is removed.

If the colonscopy is being performed due to symptoms (pain, bleeding), it is diagnostic and cost sharing does apply.

A screening test is a test provided to a patient in the absence of signs or symptoms based on the patient’s age, gender, medical history and family history according to medical guidelines. Whether a polyp or cancer is ultimately found does not change the screening intent of that procedure.

Screening Colonoscopy for Non-Medicare Patients that becomes Diagnostic or Therapeutic

When a screening colonoscopy converts to a diagnostic or therapeutic procedure for a non-Medicare patient, the surgeon must document that the intent of the procedure was screening in order for the patient’s insurance to process the claim without out-of-pocket expense in accordance with the ACA.

CPT developed the 33 modifier for preventive services...

For example, if a surgeon performing a screening colonoscopy finds and removes a polyp with a snare, use CPT code 45385 and append modifier 33 to the CPT code.

Reference: Colonoscopy Coding Guidelines | Screening Colonoscopy | ICD 10 & Modifier 33

 

[MRG]

My ACA policy covered conolosocy and polyop removal. If I received any bill it was minimal.

Forgive my ignorance but I thought once you had a polyop you were considered higher risk and cologaurd was no longer a viable option. I know it's not for me with both polyop and a sibling who had colon cancer.

My sibling almost let her fear of the procedure end her life. Please get tested!

 

[Bflotomny]

For DW & I it is not the cost of the procedure but the miserable prep. DW she was required to dose 3 times with each colonoscopy, (last year and 15 years ago.) But last year the prep process began at 5-6PM with the last dose at 4AM. Nothing like trying to sleep and then waking up to take meds.
15 years ago you began prep at noon the day before and were finished at midnight. What did they not see at midnight that they can see at 4AM??

 

[Ian S]

For DW & I it is not the cost of the procedure but the miserable prep. DW she was required to dose 3 times with each colonoscopy, (last year and 15 years ago.) But last year the prep process began at 5-6PM with the last dose at 4AM. Nothing like trying to sleep and then waking up to take meds.
15 years ago you began prep at noon the day before and were finished at midnight. What did they not see at midnight that they can see at 4AM??

There are a lot of prep methods and I think it comes down to what the individual gastroenterologist prefers. My doctor's group has several different ones but with me, my doc only seems to use one (Miralax/Ducolax/Gatorade) that utilizes inexpensive OTC materials with choice of flavor and that cleans me out well. I've never had a problem getting a good sleep (been on a 3 yr schedule due to polyps) but this year i had to get up before 6 am for the last step, a bottle of magnesium citrate. One thing I believe helps is to eat lightly two days prior to the procedure. Less material seems to translate into faster/easier clean out.

I would strongly urge that folks get their first colonoscopy when recommended i.e. age 50 for most. Don't rely on alternates. If you're like most people, you'll have no polyps and thereafter be on a ten year schedule. Cologuard actually states in ads that it's not for people with polyps so maybe after a polyp-free colonoscopy, Cologuard would be appropriate for the following decade.

 

[Rianne]

Appreciate the comments. Our hospital does charge for removing and biopsy of one or more polyps regardless of biopsy. The hospital and the insurance are linked as the hospital is self insured, it is not one of the big HI companies. Setting cost aside, there is no colon cancer in my large family, including blood relatives on my parents both sides. I guess every cell in the body has a possibility to become cancer. That brings to mind kidneys, lungs, liver, spleen, pancreas...there are no pre cancerous tests for those. Not sure why all the focus is on breast and colon cancer.

 

[braumeister]

Not sure why all the focus is on breast and colon cancer.

Because if you're not a smoker they are the biggest killers.

https://www.livescience.com/11041-10-deadliest-cancers-cure.html

 

[Hamlet]

I had my first colonoscopy this year at 45 because of family history.

The procedure wasn’t bad at all. They gave me the options of being knocked out, being awake but sedated, or no drugs at all. I took the awake but sedated option and I think that is the way to go. No risk of not waking up, but no pain or real discomfort.

The prep was moderately unpleasant.

My cost was a couple of thousand with my less than top of the line insurance.

 

[HtownRose]

Wait, we're supposed to have a chest x-ray every year? I think I've maybe had 1 my whole life, when I was in my 20s...seem to recall it was before another procedure. Never smoked, but grew up in a smoking household so plenty of 2nd hand exposure my first 18 years.

 

[JoeWras]

Because if you're not a smoker they are the biggest killers.
https://www.livescience.com/11041-10-deadliest-cancers-cure.html

And young people killers (say, less than 75).

Lots of lung cancer in my parents' generation. In my generation, where smoking is less pervasive or shorter lived, I'm seeing many peers have significant problems with colon and breast cancer. One first cousin nearly died from colon cancer in his 50s. We had a church friend die from it at 47. There have been a few people at w*rk treated for it.

Based on the genes I share with my cousin, even if only 1/16th, I decided to get the colonoscopy at 50 and it saved my life. No cancer, but significant high grade polyps which were even making me slightly anemic, even though I passed the fecal occult test every year.

I've now had 3. 2 of the 3 had polyps. Despite being on a high deductible health plan (for HSA), I have been asked to pay $0 for all if it, including the biopsies.

Now about that article... Pancreatic cancer is sneaking up the list. I pray our smart medical people in this world get a handle on the "why," and the "how" to stop this menace.

 

[Rianne]

Because if you're not a smoker they are the biggest killers.

https://www.livescience.com/11041-10-deadliest-cancers-cure.html

Good article. I guess my question is, if the preventative measures are working, why are they the biggest killers? And if smoking is one of the causes of lung cancer, could diet, exercise and lifestyle be the cause of those cancers?

I'm not trying to persuade anyone to change their mind on how to live their lives or thinking on medical issues. Medicine has come a long way. When I was 35 yrs. old, I had pre cancerous testing for breast cancer. I have ductal and lobular carcinoma in-situ and it was considered pre cancerous. My oncologist and surgeon pressured me to get chemo, radiation and a double mastectomy. Now, those pre cancer diagnosis are no longer considered a cancer threat. I did not follow the doctors suggestions and am cancer free today.

Do not take my personal experience as something you would do. Sure, I know people who never smoked in their lives and have lung cancer. How you treat your body is your choice. Obesity is a choice and we have the highest rate of obesity in the world. Could obesity be a cause of cancer?

My original post did not say..."everybody change the way you get screened for colon cancer" yet everyone is trying to say I should get a colonoscopy. I don't want to get a colonoscopy. My personal opinion is the cancer industry is huge. If we found a cure for cancer, an entire industry would collapse and millions would be out of work.

If you're interested in why I think the way I do about certain aspects of the medical industry, I'll share this podcast.

https://www.peoplespharmacy.com/2018/03/15/show-1114-how-health-care-became-big-business/

 

[JoeWras]

My original post did not say..."everybody change the way you get screened for colon cancer" yet everyone is trying to say I should get a colonoscopy. I don't want to get a colonoscopy. My personal opinion is the cancer industry is huge. If we found a cure for cancer, an entire industry would collapse and millions would be out of work.

You absolutely should be free to not get the screening, especially if you don't like the risks. And there are risks. For sure, feel free to seek alternatives. No pressure here, except our experiences may apply a little psychological pressure. For this, I apologize.

It saved my life, but my life has nothing to do with yours. YMMV.

 

[Henry Lili]

First one in January at age 51. Five polyps found and removed during procedure. No charge to me

 

[Teacher Terry]

I agree that either the Colonguard or colonoscopy is a reasonable choice. The first one doesn't detect polyps but the second has risks that the first does not.

 

[michelek]

I am scheduled for a routine colonoscopy. I went in to the doc for the first meeting and received a bill for the office visit for $275. Shouldn’t that be part of the procedure? I was surprised to get a bill for the initial meeting/ appointment to schedule the routine colonoscopy.

 

[fh2000]

I am scheduled for a routine colonoscopy. I went in to the doc for the first meeting and received a bill for the office visit for $275. Shouldn’t that be part of the procedure? I was surprised to get a bill for the initial meeting/ appointment to schedule the routine colonoscopy.

In my case, no. That is a consultation and doctor billed the insurance separately from the procedure. I had other surgeries and the first or second meetings with doctors are also billed separately from the procedure itself.

 

[NoMoreJob]

I had a Colonoscopy in 2014 under my then ACA policy. As recommended I had another very recently this time with traditional Medicare/Medigap G coverage. Both times a couple of precancerous polyps were found, removed and biopsied. Everything was covered by my insurance with $0 out-of-pocket for both procedures.

I had moved since the 2014 procedure so my current doctor needed to obtain a copy of that report prior to this year's procedure to confirm that it was medically required and would be covered by Medicare.

 

[NoMoreJob]

I am scheduled for a routine colonoscopy. I went in to the doc for the first meeting and received a bill for the office visit for $275. Shouldn’t that be part of the procedure? I was surprised to get a bill for the initial meeting/ appointment to schedule the routine colonoscopy.

I also had a preliminary meeting with a nurse practitioner which was required by the clinic. It was billed at $169, Medicare approved and paid $62.21 and my G supplement will pick up the remaining $12.44. I'm sure that I also had a preliminary appointment for the 2014 procedure under an ACA policy. I don't have the details on that one but everything was paid.

If you haven't already I'd suggest checking with the doctor's/clinic's billing department and make sure the claim was submitted and coded properly. Most often when insurance doesn't pay as expected I've found that mistakes have been made in the billing process and that alerting the billing department and asking that it be checked for accuracy and re-submitted solves the problem.

 

[MRG]

If you haven't already I'd suggest checking with the doctor's/clinic's billing department and make sure the claim was submitted and coded properly. Most often when insurance doesn't pay as expected I've found that mistakes have been made in the billing process and that alerting the billing department and asking that it be checked for accuracy and re-submitted solves the problem.

+1
Some of my career was spent around medical records management. Their number one issue is coding, or mis-coding.

I recall taking my team into a hospital implantation where one of our goals was to improve the coding thus improving turn around time in billing. The turn around time is a big metric $$$ for the hospital management. Anyway there was a couple of ladies who did coding at the hospital. When they found out who we were, they wanted to hug us.

 

[rprun54]

Cologuard wasn't covered by my insurance. Glad I checked before I used it.

I e-mailed insurance company to see if Cologuard was covered. They said it was covered. Two weeks later I received EOB in the mail. They paid nothing. My part was $649. I am fighting this.

 

[Rianne]

I e-mailed insurance company to see if Cologuard was covered. They said it was covered. Two weeks later I received EOB in the mail. They paid nothing. My part was $649. I am fighting this.

Yep, it is covered as part of your deductible. It may not be considered part of the preventative essentials. My HI now includes Cologuard as preventative essential and it is 100% paid. It was not that way 2 years ago but it applied to my deductible.

 

[rprun54]

Yep, it is covered as part of your deductible. It may not be considered part of the preventative essentials. My HI now includes Cologuard as preventative essential and it is 100% paid. It was not that way 2 years ago but it applied to my deductible.

It did not go to deductible. They said the lab was out of network. Exact Sciences Lab. Is the only Cologuard lab.

 

[zinger1457]

It did not go to deductible. They said the lab was out of network. Exact Sciences Lab. Is the only Cologuard lab.

This is part of the response I got back from BCBS-AZ when I asked them if the cost of the Cologuard was covered under preventative services.

...Benefits are limited to one (1) preventive physical exam per member, per calendar year, unless additional visits are necessary for the member to obtain all covered Preventive Services. So it would have to be either colonoscopy or the cologuard.

[FONT=&quot]Cologuard is a covered screening but the lab that processes it, Exact Sciences, is not contracted with your plan. Have your provider submit a preauthorization[/FONT]

 

[rprun54]

This is part of the response I got back from BCBS-AZ when I asked them if the cost of the Cologuard was covered under preventative services.

That’s why I contacted my plan administrator before the procedure. They just right out lied to me. I kept the e-mails for proof. Test came back negative so I don’t have to worry about a second procedure.

 

[zinger1457]

That’s why I contacted my plan administrator before the procedure. They just right out lied to me. I kept the e-mails for proof. Test came back negative so I don’t have to worry about a second procedure.

With BCBS the pre-authorization request from your doctor to BCBS is needed for most services outside of your PCP.

 

[rprun54]

With BCBS the pre-authorization request from your doctor to BCBS is needed for most services outside of your PCP.

Nobody knew it was out of network until after the fact. It was preautherized at least six days before it was done.