Medicare and Colonoscopy: some surprises.

[DrRoy]

I start Medicare next year. What fun.

 

[Koolau]

I start Medicare next year. What fun.

All in all, it's great. It's the details that can be daunting from time to time. YMMV

 

[JohnRM]

Could be worse

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.


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

Mine are always diagnostic and I have to have one EVERY YEAR due to liver problems. But when you consider that it is the EXACT SAME procedure regardless of billing, I agree this is BS

 

[Dave J]

I had one on Medicare at 65 , had a polyp and they paid all except deductible. (Plan G) I had another at 70 , had one polyp and they again paid all except deductible.

 

[RetMD21]

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.

Medicare will pay for screening every 24 months as needed. Other insurance varies. Some hospitals/clinics/doctors will bill for a diagnostic colonoscopy to make more money. Not illegal but not consumer friendly.

 

[meleana]

You should not be responsible to pay anything for a colonoscopy if you have Plan G. We have Plan G and we’ve never paid a dime out-of-pocket and we had polyps.

 

[Teacher Terry]

I had polyps the last time and didn’t pay a dime with plan g.

 

[audreyh1]

OK, well clearly Medicare messed up on this one not having DH’s Plan G cover the copay.

 

[Dean56]

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!

This is a fact and hits close to home for me. My brother was diagnosed with Stage 4 colon cancer in 2000. He had several surgeries and then chemo treatments and lived another 6 years. We lost him in 2006, at the age of 49. I had my 1st colonoscopy at age 38, I've had a total of 5 now and I don't complain at all. I've had other family members that have been diagnosed with colon cancer.

 

[RetMD21]

OK, well clearly Medicare messed up on this one not having DH’s Plan G cover the copay.

Right. The "cross-over" works the vast majority of the time. The facility can bill the secondary when it fails. Everybody wants a copy of your supplement card but usually they don't need it. This time they did

 

[Scuba]

I’m not on Medicare yet, but just had a colonoscopy. Polyps were found and removed, fortunately benign, but I had to pay in full for the procedure because I hadn’t met my high deductible. Ouch!

 

[ShadowBloom]

I'm not on Medicare and my colonoscopy bill was the best kind of surprise. I was having digestion issues, and both I and the hospital thought it would be considered diagnostic. The hospital provided me an estimate of my responsibility being several thousand dollars and they wanted payment upfront. I convinced them to wait until after the EOB came and it's a good thing I did--apparently since I'd never had a colonoscopy before and this one didn't find anything, my insurance considered it screening and I didn't owe anything for it!

 

[RetMD21]

I'm not on Medicare and my colonoscopy bill was the best kind of surprise. I was having digestion issues, and both I and the hospital thought it would be considered diagnostic. The hospital provided me an estimate of my responsibility being several thousand dollars and they wanted payment upfront. I convinced them to wait until after the EOB came and it's a good thing I did--apparently since I'd never had a colonoscopy before and this one didn't find anything, my insurance considered it screening and I didn't owe anything for it!

It would be interesting to know how it was coded. The hospital might have made an error that worked out for you.

 

[pacergal]

DH is on a schedule every 5 years, due to family history of colon cancer and he has polyps removed every time.
Just had his in October, no cost with our medicare Advantage plan.

 

[ShadowBloom]

It would be interesting to know how it was coded. The hospital might have made an error that worked out for you.

Yeah-- I was surprised and curious when I got the EOB from my insurance, but I wasn't about to call and ask questions that might result in reversing their decision!

 

[RetMD21]

Yeah-- I was surprised and curious when I got the EOB from my insurance, but I wasn't about to call and ask questions that might result in reversing their decision!

Exactly