Billed for screening colonoscopy?

[frank]

when I had a colonoscopy they charged me 85. for self administered drugs. I questioned that but could not get an answer. what drugs do you self administer in a colonoscopy? I was told they would have to check the files and would get back to me, but I never got an answer. coding for these insurance companies is so easy to get wrong. another time they tried to bill me for the whole procedure and when I asked why they said my lifetime insurance allowed amount was already used up. when they saw it coded that way they changed the code and took care of the bill. always check how your charges are coded if something isn't covered.

 

[SecondCor521]

when I had a colonoscopy they charged me 85. for self administered drugs. I questioned that but could not get an answer. what drugs do you self administer in a colonoscopy?

It's probably the stuff they ask you to drink the night before.

 

[FIREd_2015]

My wife and I recently had our age 50+ colonoscopy done.

Neither of us had any pre-existing conditions, previous tests, stool samples, etc.

My procedure had no issues, no polyps found and I was charged $0, all covered under insurance.

My wife's procedure they removed 2 benign polyps and she was charged $550 into our copay because of the polyp removal. They essentially changed the procedure from a screening to a diagnostic while she was under anesthesia.

I had thought and was told colonoscopy was covered 100% if there had not been any previous history or tests and you were of the right age and other factors.

I contacted the hospital and they are sticking by the codes they filed for the procedure and told me to contact my insurance company. I have not made progress with the insurance company as of yet.


Is this correct under current law? Does a procedure change because of the discovery of polyps? I can understand it changing for the next time you have a colonoscopy, but does it change while you are under?

edit: I found this on cancer.org

"Soon after the ACA became law, some insurance companies considered a colonoscopy to no longer be just a ‘screening’ test if a polyp was removed during the procedure. It would then be a ‘diagnostic’ test, and would therefore be subject to co-pays and deductibles. However, the US Department of Health and Human Services has clarified that removal of a polyp is an integral part of a screening colonoscopy, and therefore patients with private insurance should not have to pay out-of-pocket for it (although this does not apply to Medicare, as discussed below)."

I ran into the same problem when I had my colonoscopy in 2019. Here is the link to my post from 2019:

https://www.early-retirement.org/fo...-aca-coverage-quirks-and-headache-101293.html

 

[N02L84ER]

You do have to check the billing codes. DH went to the ER for a gallbladder issue and the bill had a charge for an X-ray of a broken arm. An older gentleman had come in after a fall while DH was in the imaging room and somehow the older guy's charge was put on DH's bill. We checked every single billing code and got it all straightened out, we think.

 

[nwsteve]

Article from NPR today with identical circumstances--wrong billing code and provider refuses to correct--https://www.npr.org/sections/health-shots/2022/05/31/1101861735/colonoscopy-cost-cancer-screening
Interesting remark from article
"Remind your provider that the government's interpretation of the ACA requires that colonoscopies be regarded as a screening even if a polyp is removed."

 

[RetMD21]

Article from NPR today with identical circumstances--wrong billing code and provider refuses to correct--https://www.npr.org/sections/health-shots/2022/05/31/1101861735/colonoscopy-cost-cancer-screening
Interesting remark from article
"Remind your provider that the government's interpretation of the ACA requires that colonoscopies be regarded as a screening even if a polyp is removed."

Actually, this one is different in that Ms Melville had a previous polyp so some facilities (Loyola in my link above) will intentionally and possibly legally bill diagnostic. I think it is unconscionable but probably legal.

 

[nwsteve]

My apologies--you are, of course< correct. I was referring more to the provider insisting they had correct billing code. Clearly there was a difference in the patient clinical details, but provider ignorance of proper legal billing was the same

 

[Koolau]

It's probably the stuff they ask you to drink the night before.

$1 worth of crystal Gator Aid and $.50 worth of mag sulfate. But, hey, it comes in that really nice reusable mixing bottle! YMMV

 

[Sunset]

Fermion, polyps were found/removed during my first colonoscopy, and I was charged for the pathology but nothing else in the procedure. (Believe me, it was enough!) I'm ALWAYS billed for pathologists and radiologists because they're not on the list of preferred doctors for my HMO. Healthcare here is such a racket that I've considered emigrating to another country, but DH has good free VA care as a disabled vet. So it kind of balances out financially.

Every time we had HMO (Horrible Medical Option) it was bad if we needed anything done.
When we had PPO it was more expensive but paid for everything no problem.

 

[ransil]

my first one 3 years ago they charged me about $1400 for a polyp removal larger one, second one last month no charges on my parts so far, they removed 2 small polyp my insurance has not changed, they coded everything this time ANCILLARY SERVICES

 

[Cobra9777]

Our experience with this has been all over the map...

DW had a screening colonoscopy with one polyp removed. Insurance paid in full. Five years later, she had another colonoscopy, which was clean. The doctor coded it as diagnostic based on the prior polyp. So she had to pay deductible and coinsurance. But the facility and anesthesiologist both coded it as preventative. So their (larger) part was fully paid by insurance.

I had a screening colonoscopy with two polyps removed. Insurance paid in full. Five years later, I had another colonoscopy, which was clean. The doctor (same GI that DW uses) coded it as preventative and insurance fully paid. Facility and anesthesiologist did the same.

The prep drugs were fully paid under my insurance both times. DW's had to pay for the prep drugs the first time. But it was fully paid the second time, which is exactly the opposite of the doctor's coding.

There seems to be no consistency at all based on our experience. Even with the same doctor. Also no coordination between doctor, facility, and pharmacy. I asked the GI billing person about the inconsistency between DW's and my cases. She said it's completely up to the discretion of the doctor as to how it's coded and not JUST dependent on whether or not there was a prior polyp. She also said the facility and anesthesiologist should always follow the doctor, but she was aware that sometimes they do not.

 

[Koolau]

Our experience with this has been all over the map...

DW had a screening colonoscopy with one polyp removed. Insurance paid in full. Five years later, she had another colonoscopy, which was clean. The doctor coded it as diagnostic based on the prior polyp. So she had to pay deductible and coinsurance. But the facility and anesthesiologist both coded it as preventative. So their (larger) part was fully paid by insurance.

I had a screening colonoscopy with two polyps removed. Insurance paid in full. Five years later, I had another colonoscopy, which was clean. The doctor (same GI that DW uses) coded it as preventative and insurance fully paid. Facility and anesthesiologist did the same.

The prep drugs were fully paid under my insurance both times. DW's had to pay for the prep drugs the first time. But it was fully paid the second time, which is exactly the opposite of the doctor's coding.

There seems to be no consistency at all based on our experience. Even with the same doctor. Also no coordination between doctor, facility, and pharmacy. I asked the GI billing person about the inconsistency between DW's and my cases. She said it's completely up to the discretion of the doctor as to how it's coded and not JUST dependent on whether or not there was a prior polyp. She also said the facility and anesthesiologist should always follow the doctor, but she was aware that sometimes they do not.

Sounds like this is the kind of discussion that needs to be had before the procedure. YMMV

 

[FindingForward]

I paid $55 for the prep fluid because it was a newer brand name formula not approved by insurer. But it was the one doc recommended as best to tolerate.

All gastro docs here require a separate upfront office visit/exam before scheduling a colonoscopy. My insurer tried to bill me $275 for this "office visit" claiming it didn't count as part of "free" coloscopy screening. (I have a high deductible plan: non-preventive is 100% out of pocket until deductible met.)

But to me, if every doc requires it as a basic part of colonoscopy, then it should be included, as it's not an option the patient can decline?

Very long story short: insurer retracted bill. But boy, they made me work for it.

 

[Koolau]

I paid $55 for the prep fluid because it was a newer brand name formula not approved by insurer. But it was the one doc recommended as best to tolerate.

All gastro docs here require a separate upfront office visit/exam before scheduling a colonoscopy. My insurer tried to bill me $275 for this "office visit" claiming it didn't count as part of "free" coloscopy screening. (I have a high deductible plan: non-preventive is 100% out of pocket until deductible met.)

But to me, if every doc requires it as a basic part of colonoscopy, then it should be included, as it's not an option the patient can decline?

Very long story short: insurer retracted bill. But boy, they made me work for it.

Interesting. I never met the doc doing the procedure until I was wheeled into the procedure room. SO no office visit - before or after. YMMV

 

[RetMD21]

All gastro docs here require a separate upfront office visit/exam before scheduling a colonoscopy. My insurer tried to bill me $275 for this "office visit" claiming it didn't count as part of "free" coloscopy screening. (I have a high deductible plan: non-preventive is 100% out of pocket until deductible met.)

You know that the doc billed you, right? It isn't considered standard but hey, if you can pad the bill why not?

Here's a link saying it isn't billable but I guess opinions differ

https://www.aapc.com/blog/27288-sep...al Surgery Fact,in the global surgery package.

 

[sestein1]

I had one at a GI outpatient center and they coded it as diagnostic (which I was unaware of). I then received an EOB from my insurance company saying that the full amount (less their discount) was being applied to my deductible and I was responsible for the whole amount. I called to inquire and advised that it was a screening procedure. They told me that it had been improperly coded and to ask the provider to resubmit.

I called my Dr's office. They reviewed my file, confirmed that it was a screening procedure, resubmitted their claim appropriately and also ensured that the facility and other providers did the same. If you have to deal with the hospital directly, I would simply tell them that they can either submit appropriately and be paid by your insurer or continue to submit inaccurately and be paid nothing by you.

 

[KarenF]

My wife and I recently had our age 50+ colonoscopy done.

Neither of us had any pre-existing conditions, previous tests, stool samples, etc.

My procedure had no issues, no polyps found and I was charged $0, all covered under insurance.

My wife's procedure they removed 2 benign polyps and she was charged $550 into our copay because of the polyp removal. They essentially changed the procedure from a screening to a diagnostic while she was under anesthesia.

I had thought and was told colonoscopy was covered 100% if there had not been any previous history or tests and you were of the right age and other factors.

I contacted the hospital and they are sticking by the codes they filed for the procedure and told me to contact my insurance company. I have not made progress with the insurance company as of yet.


Is this correct under current law? Does a procedure change because of the discovery of polyps? I can understand it changing for the next time you have a colonoscopy, but does it change while you are under?

edit: I found this on cancer.org

"Soon after the ACA became law, some insurance companies considered a colonoscopy to no longer be just a ‘screening’ test if a polyp was removed during the procedure. It would then be a ‘diagnostic’ test, and would therefore be subject to co-pays and deductibles. However, the US Department of Health and Human Services has clarified that removal of a polyp is an integral part of a screening colonoscopy, and therefore patients with private insurance should not have to pay out-of-pocket for it (although this does not apply to Medicare, as discussed below)."

I have had 5 colonoscopies due to a family history of colon cancer. I have ever been billed for the prep or the procedure, but they have never removed anything. I would think it is like surgery - if they find something while doing it they add those codes. On the other hand, I have been called back for diagnostic mammograms after having a screening mammogram and never had to pay anything. I don't know the answer but it is hard to fight things like this. Can you contact the Insurance Commissioner in your state?

 

[Fermion]

Update! We actually finally got the insurance company to agree to pay the bill in its entirety. It only took like three months.

Now I have to figure out how to get the hospital to refund me the $550 we paid them after they get the $550 more from the insurance company.

 

[pacergal]

Thats good news. I would think they would send it too you automatically, but if it were me, I would be calling and asking for it as soon as insurance payment posted!

 

[MichaelB]

Update! We actually finally got the insurance company to agree to pay the bill in its entirety. It only took like three months.

Now I have to figure out how to get the hospital to refund me the $550 we paid them after they get the $550 more from the insurance company.

The revised EOB should clearly indicate the amount the hospital can charge. Once it’s available I’d call the billing dept and follow up with a letter.

 

[SecondAttempt]

My wife and I recently had our age 50+ colonoscopy done.

Neither of us had any pre-existing conditions, previous tests, stool samples, etc.

My procedure had no issues, no polyps found and I was charged $0, all covered under insurance.

My wife's procedure they removed 2 benign polyps and she was charged $550 into our copay because of the polyp removal. They essentially changed the procedure from a screening to a diagnostic while she was under anesthesia.

I had thought and was told colonoscopy was covered 100% if there had not been any previous history or tests and you were of the right age and other factors.

I contacted the hospital and they are sticking by the codes they filed for the procedure and told me to contact my insurance company. I have not made progress with the insurance company as of yet.


Is this correct under current law? Does a procedure change because of the discovery of polyps? I can understand it changing for the next time you have a colonoscopy, but does it change while you are under?

edit: I found this on cancer.org

"Soon after the ACA became law, some insurance companies considered a colonoscopy to no longer be just a ‘screening’ test if a polyp was removed during the procedure. It would then be a ‘diagnostic’ test, and would therefore be subject to co-pays and deductibles. However, the US Department of Health and Human Services has clarified that removal of a polyp is an integral part of a screening colonoscopy, and therefore patients with private insurance should not have to pay out-of-pocket for it (although this does not apply to Medicare, as discussed below)."

There was a story on NPR about this a few weeks ago. If I recall correctly, the change to a diagnostic procedure vs screening is correctly triggered if they remove a polyp. I cannot comment on your specific details except to say that the examples in the NPR story were charged thousands of dollars so you may have been lucky!

 

[MBSC]

There was a story on NPR about this a few weeks ago. If I recall correctly, the change to a diagnostic procedure vs screening is correctly triggered if they remove a polyp.

No. Screening vs Diagnostic is based on personal and family history for the ACA. Read the story again, please.

Colonoscopies are supposed to be free but patients have reported getting billed

Preventative health care like mammograms and colonoscopies are meant to be free of charge to patients under the Affordable Care Act, but there are some exceptions.

Some patients may be billed for the procedure if it's for "diagnosis" versus "screening" purposes. For instance, people with a family history of colon cancer or a personal history of polyps are likely to have a higher risk of cancer and therefore, see their colonoscopy classified as "diagnostic."

It's important to note polyp removals are not enough to be considered "diagnostic" under the law. Because there's little federal oversight around this provision, the onus is up to the patient to ensure they are billed correctly.

https://www.npr.org/2022/09/19/1123...n-cancer-colonoscopy-awareness-rob-mcelhenney

In original Medicare:

Colonoscopies: Medicare covers this screening test once every 120 months (or every 24 months if you’re high risk) or 48 months after a previous flexible sigmoidoscopy. There’s no minimum age requirement. You pay nothing for the test if your doctor or other qualified health care provider accepts assignment.

NEW - Note: If your doctor finds and removes a polyp or other tissue during the colonoscopy or flexible sigmoidoscopy, you pay 15% [20% before 2023] of the Medicare-approved amount for your doctors’ services. In a hospital outpatient setting, you also pay the hospital a 15% coinsurance. The Part B deductible doesn’t apply.

2023 Medicare & You (page 35): https://www.medicare.gov/publications/10050-Medicare-and-You.pdf