Medicare and Colonoscopy: some surprises.

[audreyh1]

DH and I have been down a bit of a rabbit hole trying to understand the Medicare billing for a screening colonoscopy DH had early in the year.

We would perhaps have never even noticed except that DH visited an Ophthalmologist late in the year and we were shocked that he hadn’t already met his deductible.

DH has traditional Medicare plus Medigap Plan G.

So it turns out that for the colonoscopy, because they found a polyp and removed it, the charging was different. Nothing was applied to the deductible. Instead DH was charged a 15% coinsurance for the procedure. We had fallen into the Medicare colonoscopy loophole.

What is the Medicare colonoscopy loophole?

The "Medicare loophole" happens when your routine colonoscopy screening detects medical issues. When that occurs, your test is no longer considered a screening and is no longer free. It then becomes a diagnostic procedure, and you're charged the 20% Medicare coinsurance.

In 2020, a "Medicare loophole" law was passed that protects Medicare patients who get a screening colonoscopy that turns into a diagnostic procedure.
The law, called the Removing Barriers to Colorectal Cancer Screening Act, gradually reduces Medicare patients' coinsurance and will eliminate out-of-pocket costs completely by 2030. The colonoscopy procedure itself will not change, just how patients are billed.

Meanwhile, if you're billed for a colonoscopy screening, you may want to contact your provider or Medicare (at 800-633-4227 or Medicare.gov) to be sure you are charged the correct amount.

From https://www.valuepenguin.com/does-medicare-cover-colonoscopy

So the rate for 2023 the coinsurance was apparently 15%. This silliness will eventually go away but not until 2030.

If it was not applied against our deductible, but instead we were charged a coinsurance amount, why was that not sent to our Medigap insurer for them to pay it? Medicare.gov knows who that is. Is there some other weird related loophole that a Medigap policy doesn’t cover this? Do Plan F insured have to pay out of pocket too?

Another informative reference regarding Medicare coverage for colonoscopy:

Why Did Medicare Charge Me for a Colonoscopy? https://www.verywellhealth.com/medicare-colonoscopy-5120481

 

[MichaelB]

It even has its own name! This is crazy.

 

[aja8888]

DH and I have been down a bit of a rabbit hole trying to understand the Medicare billing for a screening colonoscopy DH had early in the year.

Welcome to the wonderful world of Medicare!

I've been in it 15 years and still getting surprises.

 

[audreyh1]

It even has its own name! This is crazy.

Yeah, and loops and holes and falling into something sounds pretty punny too, huh?

 

[audreyh1]

Welcome to the wonderful world of Medicare!

I've been in it 15 years and still getting surprises.

Well it was a good training exercise for DH who was extremely frustrated about trying to decipher the whole mess, even though he had tracked his bills and payments. For him the funds involved were small, so he was annoyed at having to figure this out. I told him that we needed to get a handle on it now, because I could see things potentially getting worse in the future. Learning curve.

I think he has a much better understanding of how to track things more effectively now, what to focus on and what he can ignore. Hopefully this will make things easier.

 

[grasshopper]

Medigap G should pick up the 20% that Medicare B doesn't cover. And yes the remained 20% should have been sent to the the medigap insurer.
Veghead almost vegan and I have had polyps ever since my first colonoscopy 25 years ago. I have never paid anything out of pocket between Medicare and medigap G besides my deductible.

 

[Qs Laptop]

When I got my most recent colonoscopy, Jan 2022, I asked the doctor to let me know if he finds anything else going on as I had been having off-and-on cramp-like symptoms for a couple of months. He told me he's not supposed to do that because if he does, it's no longer is consider a routine screening but is also a diagnostic procedure. This seemed odd to me.

This sounds exactly like the reasoning your husband received for his procedure.

 

[audreyh1]

When I got my most recent colonoscopy, Jan 2022, I asked the doctor to let me know if he finds anything else going on as I had been having off-and-on cramp-like symptoms for a couple of months. He told me he's not supposed to do that because if he does, it's no longer is consider a routine screening but is also a diagnostic procedure. This seemed odd to me.

This sounds exactly like the reasoning your husband received for his procedure.

What’s weird is that diagnostic colonoscopies are completely covered by Medicare if you have a Medigap plan less possibly the annual deductible. So it is odd that this screening procedure that found something to remove charged differently.

 

[audreyh1]

Medigap G should pick up the 20% that Medicare B doesn't cover. And yes the remained 20% should have been sent to the the medigap insurer.
Veghead almost vegan and I have had polyps ever since my first colonoscopy 25 years ago. I have never paid anything out of pocket between Medicare and medigap G besides my deductible.

OK - we’ll pursue that angle now.

 

[MarieIG]

Oh yes, I have heard of this.


I have a super-secret plan to ask my oncologist to refer me for another colonoscopy before my 65th birthday.

 

[braumeister]

I have a super-secret plan to ask my oncologist to refer me for another colonoscopy before my 65th birthday.

What a wonderful way to celebrate a milestone birthday!

Kidding aside, I've had a couple of Medicare colonoscopies and haven't paid a nickel, except for the prep. I could have charged that off as well, but given a choice I opted for one that wasn't covered.

 

[MarieIG]

What a wonderful way to celebrate a milestone birthday!

Kidding aside, I've had a couple of Medicare colonoscopies and haven't paid a nickel, except for the prep. I could have charged that off as well, but given a choice I opted for one that wasn't covered.

I don't recall the name of the prep that I had last time, I just know I don't want it again!

 

[audreyh1]

Kidding aside, I've had a couple of Medicare colonoscopies and haven't paid a nickel, except for the prep. I could have charged that off as well, but given a choice I opted for one that wasn't covered.

Probably because they didn’t find anything. If they do have to remove something then the billing arrangement changes.

 

[GenXguy]

Probably because they didn’t find anything. If they do have to remove something then the billing arrangement changes.

Exactly. I was concerned about this in advance of my colonoscopy on my employer insurance because it could have made a difference of $1000 or so out of my pocket if it was not considered preventative. Thankfully, it was smooth sailing and free.

 

[braumeister]

Probably because they didn’t find anything. If they do have to remove something then the billing arrangement changes.

No, polyps were found and removed each time.

 

[audreyh1]

No, polyps were found and removed each time.

OK - clearly there was a billing error in our case. The coinsurance should have been billed to our Medigap insurer.

 

[savory]

I got caught for $2,000 several years ago when I filled out the form that on a previous exam, they found a polyp. I did not know but that put me in a pay for service, polyp or no polyp. It was just a surprise since the exam was positioned as a preventative procedure, like a physical. Now, if the doc would have tossed in a physical while he was back there maybe I would have felt better about the whole thing.

 

[fosterscik]

Medigap G should pick up the 20% that Medicare B doesn't cover. And yes the remained 20% should have been sent to the the medigap insurer.
Veghead almost vegan and I have had polyps ever since my first colonoscopy 25 years ago. I have never paid anything out of pocket between Medicare and medigap G besides my deductible.

Me too. I've had 1 colonoscopy on Medicare, polyps found and removed, and am now on a 3 year screening schedule. Medicare G picked up all additional costs, so no charge for me (I'd already filled the G deductible that year).

 

[Dtail]

I get polyps removed each time, so will make sure my next colonoscopy is next year before reaching Medicare, as I will probably go the Med Advantage route.

 

[MissMolly]

On my MA plan 100% covered including the removal of a polyp.

 

[Dtail]

On my MA plan 100% covered including the removal of a polyp.

Nice, will check that out in due time from potential plans.

 

[fh2000]

I had a colonoscopy close to the end of last year (2022). One polyp was removed. I checked my account on Medicare.gov, I can see that it listed that I might be charged for Surgical center ($123), and 2 other doctor charges.

But since I had already met my deductible, I did not get charged anything.

 

[Chuckanut]

It even has its own name! This is crazy.

My previous colonoscopy was interesting as I was right next to a guy who had had part of his colon removed due to cancer. The cloth drape between us was not sound proof. He spent a few minutes telling the nurse prepping him about all the things he had to do now that he only had a bit of his colon left ;;;.

If you owe money be glad and pay with a smile. It's a huge killer, and even if you live...... life will never be the same. And it is the only organ inside of us that can be easily inspected visually by the doctor and problems easily removed. Lucky us!

 

[GenXguy]

I get polyps removed each time, so will make sure my next colonoscopy is next year before reaching Medicare, as I will probably go the Med Advantage route.

There was a story on national network news last evening about Medicare Advantage plans declining 20% of routine care claims. It was resulting in care no longer being available at facilities or shutting them down.

 

[Koolau]

My previous colonoscopy was interesting as I was right next to a guy who had had part of his colon removed due to cancer. The cloth drape between us was not sound proof. He spent a few minutes telling the nurse prepping him about all the things he had to do now that he only had a bit of his colon left ;;;.

If you owe money be glad and pay with a smile. It's a huge killer, and even if you live...... life will never be the same. And it is the only organ inside of us that can be easily inspected visually by the doctor and problems easily removed. Lucky us!

That's an excellent attitude. Cheap at 10X the price if it saves your life or saves you from a colostomy. Still, MC can be inscrutable at times - especially for the uninitiated. YMMV