Colonoscopy - 5 years - Insurance Coverage

[PaunchyPirate]

I'm wondering if anyone has information on my colonoscopy situation with respect to insurance coverage....

5 years ago this coming December, I had my first colonoscopy (age 53) which found 3 benign polyps that were removed. I was advised that since they found polyps I should schedule my next colonoscopy in 5 years. At the time, my PCP was Dr. A, the doctor doing the colonoscopy was Dr. B and my employer-provided insurance was with Insurer X. Insurance paid 100% of the costs of the procedure.

I'm thinking about setting an appointment for my next colonoscopy for this December. I have retired and have moved 90 minutes away from where I was 5 years ago.

So now, my PCP is a new Dr. C. My self-purchased insurance is now with Insurer Y. I can either choose to drive 90 minutes to again have Dr. B do the colonoscopy or I can pick a new doctor closer to me. I don't have a strong preference on the doctor doing the procedure.

My question is around the fact that some insurers seem to consider a 5-year followup after polyps to no longer be a routine screening and will require me to pay for more of the costs.

Will the new insurer know about the one from 5 years ago? I will talk to my PCP tomorrow and will run it by him, but I would think his order will be for a routine screening, right? He doesn't have access to the old results from 5 years ago (although I have told him about it).

How does this all play out? Any tips?

 

[Bamaman]

You can always call your insurance carrier directly and verify what coverages you have and what hoops you'll need to jump through.

They can be a $6,000 procedure, so getting the best info. on front end is important. You don't want any surprises.

 

[Aerides]

Aside from the insurance angles, you might just want to make the switch now to someone local. What if you need to do a 6 month follow up after this one? (DH has his tomorrow). Plus someone else needs to drive you so that's their day as well.

Oh, and after finishing the prep.. and all that water the morning of... I don't think I'd want to risk that long of a car trip myself.

 

[sengsational]

I think you might have to suppress details in order to get the procedure as a screening.

Picking a new scope operator (aka GI doctor) isn't a problem, and you have a new PCP. But if any of your medical history leaked from your old PCP, it's probably game-over. You could "come clean" once the insurance company pays, but the docs won't join you in hiding the fact that you're on the 5 year plan.

 

[skipro33]

Let your PCP submit a referral for a colonoscopy to your insurance company and wait to see if your insurance company approves it. If they do, and I'm gonna guess they will because A; you are new to them and they don't review your medical history past the initial sign-up and B; because if they did have wind of a past procedure, updated practice is to increase exams for those who have history of polyps, your problem is over.

 

[braumeister]

You can always call your insurance carrier directly and verify what coverages you have and what hoops you'll need to jump through.

That seems reasonable.

FWIW, my first colonoscopy found and removed some benign polyps and the doc wanted me to have another one in seven years instead of the usual ten.

My insurance had no problem with that, and I used the same doc again.

 

[CRLLS]

You will probably fill out a medical history form at your 1st visit to Dr C I wouldn't suppress any info regarding the previous colonoscopy findings. He might be extra attentive during your procedure knowing your history.

 

[JoeWras]

My insurer covered a 1 and 3 year follow up 100%, even though I had high deductible.

My specialist (GI) doctor's office did the leg work ahead to make sure it was covered. I have no idea what they told insurance. We didn't proceed until we got pre-approval. I suggest whatever you do, make sure you know ahead what to expect.

 

[PaunchyPirate]

Thanks everyone. OP here. This is all good info. I'm pretty sure I'll switch to a local GI for the procedure and I will discuss the process with my PCP in the morning. Fun stuff!

 

[RetMD21]

This is complicated but it looks like the repeat procedure is still screening and should be covered. The GI billing people wold know about this https://bulletin.facs.org/2016/05/coding-and-reimbursement-for-colonoscopy/

 

[badatmath]

I get them every 5 years and they are covered - started young due to family history. My insurance specifically states this in the SPD. (I am considered "high risk").