Billed for screening colonoscopy?

[Fermion]

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)."

 

[pacergal]

We have never been billed for screening colonoscopy, but have never had polyps removed either.
Have you called ins company and hospital with those findings from Dept of health/cancer.org? It would be interesting to see what they say.

 

[Fermion]

Found this on a government website:

https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs12

"Q5: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the USPSTF recommendation, is it permissible for a plan or issuer to impose cost-sharing for the cost of a polyp removal during the colonoscopy?

No. Based on clinical practice and comments received from the American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and the Society for Gastroenterology Nurses and Associates, polyp removal is an integral part of a colonoscopy. Accordingly, the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure. On the other hand, a plan or issuer may impose cost-sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service."

 

[MichaelB]

It’s not surprising the hospital billed for a procedure that is not eligible for reimbursement. This is common and one unfortunate aspect of a dysfunctional health care system.

It is unusual for an insurance company to acknowledge the charge as legitimate. Insurance companies are required to have clear dispute processes, so I would file a dispute and complain to the state insurance regulator.

 

[RetMD21]

My understanding is that the screening would be covered but if they convert it to diagnostic the insurance will require you to pay deductibles and co-pays. Of course, the hospital/provider wants to maximize revenue. The hospital is probably pretty confident about their billing on this.

https://www.gastroconsa.com/screening-vs-diagnostic-colonoscopy-whats-the-difference/

 

[RetMD21]

It is unusual for an insurance company to acknowledge the charge as legitimate. Insurance companies are required to have clear dispute processes, so I would file a dispute and complain to the state insurance regulator.

I don't know if you can fault the insurer for considering it a diagnostic procedure if that is how it was billed.

 

[lawman]

Traditional Medicare handles that exactly as the hospital did.

 

[SecondCor521]

I had my age-50 first screening colonscopy done a few years ago. They found and removed one polyp. I assume they billed it as a screening procedure, because my out of pocket was $0. This was on an ACA insurance plan.

My opinion is that the hospital is in the wrong. I think they are referring you to your insurance company just to get you off the phone and hoping you give up and just pay. If it were me, I would stand my ground, discuss it further with the hospital and present your research. If they still refuse to budge, I would contact whomever regulates the hospital in your state (department of insurance, maybe?) and file a formal complaint. I'd notify my insurance company as a courtesy, so they don't pay out for (what I think is) an erroneously billed procedure.

Note: the above is assuming you're on private insurance either through your employer or an ACA plan. If you're on Medicare, Tricare, or a grandfathered plan or some other situation, I have no idea what the right answer is, and I'd probably call my insurance company and ask them to help clarify the situation.

ETA: This was also done in the gastroenterologist's office, not in a hospital.

 

[lawman]

https://www.aarpmedicareplans.com/medicare-articles/does-medicare-cover-a-colonoscopy.html

 

[RetMD21]

Loyola will charge you for a diagnostic colonoscopy if your grandfather had a polyp and they aren't shy about it. It is on their web site: https://www.loyolamedicine.org/assets/documents/forms/digestive-health/colonoscopy-faqs.pdf

 

[JoeWras]

Don't go to hospitals if you can avoid it. Besides their complete dysfunctional operations, they are also germ laboratories. And many of them claim "non-profit" status on top of all that.

I get my colonoscopies at a GI center. They know what they are doing, they know how to treat their patients, and they know how to code for insurance. I've had 3 in 6 years, 2 times polyps removed. No charge any time.

 

[Boose]

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.

 

[Boose]

P.S. I earned back some of the deductible by participating in one of those colonoscopy studies that are advertised on Facebook. It was a legit company that is trying to develop a noninvasive test for precancerous polyps.

 

[PaunchyPirate]

My first colonoscopy found 3 polyps and was fully covered by my employer-provided United Healthcare insurance. My second colonoscopy 5 years later found 1 polyp and was fully covered by my ACA exchange Gold plan from UPMC Health Insurance. 2 different Doctors and Hospitals were used. The second Doctor’s office told me I would likely have to pay part of the costs since I had a recorded history of polyps. However, my insurance paid the full portion of the negotiated rates.

Maybe I just was lucky.

 

[Fermion]

Thanks for the responses. I have applied for dispute of the charges with our ACA insurance plan so we will how that goes. I am not holding my breath on this, it is gonna be a case of a tiny fish against a big shark, but I think this is the first step. After they deny me, I will send all the information to the state, who really can't do much either, according to their website.

I get the feeling this is the first of many times we will be disappointed with insurance as we grow older.

 

[SecondCor521]

a tiny fish against a big shark

"Right makes might" - A. Lincoln.

 

[Montecfo]

Good for you Fermion!

please keep us updated.I think this billing is bull stuff!

Sorry for the language.

 

[Involuntary Retiree]

Appeal your insurance company's decision in accordance with the appeal procedures outlined in your plan document. I've done it and was successful. Attach as exhibits to your appeal any information you can find on Google with respect to screening colonoscopies after a certain age and any correspondence from your healthcare provider saying, "It's time for your colonoscopy screening." Let them know by appealing that resolving your issue is going to be time-consuming, and especially for a $500 copay, your insurance company may see the issue your way quickly. I mean, what have you got to lose except for your time and some paper and ink costs?

 

[RetiredAndLovingIt]

I hope you win but if you don't, go back to the hospital and negotiate that amount down as much as you can. I think they will work with you, there was a previous discussion about asking providers to reduce the amount owed a couple of years ago and most people were able to get it discounted.

 

[Yoheadden]

Good luck with your dispute. It sounds like you Leg to stand on.
I had my first last year with no polyps found. There were charges from 2 pathologists. 1 was covered, 1 wasn’t. When I called my insurance co to question it, they didn’t know why I was charged because they were both coded the same way. They resubmitted it and sure enough, they covered it.
What wasn’t covered was the prep medication. When I questioned it, my insurance co said the procedure is 100% covered, but medicines were not. How ridiculous is that.

 

[Yoheadden]

I hope you win but if you don't, go back to the hospital and negotiate that amount down as much as you can. I think they will work with you, there was a previous discussion about asking providers to reduce the amount owed a couple of years ago and most people were able to get it discounted.

We do this with any billing through our local hospital. When you call the billing office ask if they offer a discount if you pay in full. Most do.

 

[Morgan22]

Fermion, maybe this document will help with your disputed charges. (If you haven't already found it yourself.) Page 11 mentions colonoscopies and what should be included as preventative. Also has has links to dol and cms websites mentioning the same.

https://www.dol.gov/sites/dolgov/fi...tivities/resource-center/faqs/aca-part-51.pdf

 

[SoClose]

After turning 50 and having my colonoscopy, I received a bill for $5,000! The hospital and insurance company kept pointing fingers at each other with which code. As a patient I had to learn about codes and fight like crazy, Idiotic!

After hours on phone, letters and emails where neither would budge. I told them I would never pay this bill as it should be 100% covered.

Insurance company finally sends me a letter, that as a “courtesy” they would cover the bill. Ughhhhhhh!

Our system is very flawed

 

[RetMD21]

After turning 50 and having my colonoscopy, I received a bill for $5,000! The hospital and insurance company kept pointing fingers at each other with which code. As a patient I had to learn about codes and fight like crazy, Idiotic!

After hours on phone, letters and emails where neither would budge. I told them I would never pay this bill as it should be 100% covered.

Insurance company finally sends me a letter, that as a “courtesy” they would cover the bill. Ughhhhhhh!

Our system is very flawed

The system is a mess. The codes let you know if the insurer is really obligated. One woman got hers covered after reporters started asking questions. The hospital discovered a "mistake." lol. https://khn.org/news/article/surprise-medical-bill-colonoscopy-screening-versus-diagnosis/

 

[JoeWras]

If possible, have the procedure in a place other than a hospital. Otherwise, you get wrapped up into the hospital-insurance complex.