Colonoscopy and ACA coverage quirks and headache

[fh2000]

I have done 3 in out patient surgical center, with 1-4 polyps each time. So, I have been on 5 year cycle. I remember I had to pay for the prep medicine and polyps removal, with few hundred dollars with my work PPO plan. No problem.

My next one is in 2 years when I am in Medicare. If I have Medicare+Medigap Plan G, will I need to pay anything on top of the deductible ($198 for 2020)?

[FIREd_2015]

Quote:

Originally Posted by travelover This the part that drives me nuts. Granted not every colonoscopy is the same, but these price variances are insane.

My $9k+ colonoscopy was performed at a clinic operated by one of the large hospital groups in Northern California that recently agreed to pay $575 million to settle claims of anti-competitive behavior brought by the California state attorney general's office. I would hate to know what the cost would have been if I had gone to one of their hospitals. Hey, somebody's gotta pay for those expensive mansions in some of the most expensive zip codes in the country and now this $575 million fine.

[Just_Steve]

My last colonoscopy cost me 2 x $20 copay. I dread medicare.

[travelover]

Quote:

Originally Posted by Just_Steve My last colonoscopy cost me 2 x $20 copay. I dread medicare.

Why? I had a colonoscopy under Medicare and it cost me nada.

[aja8888]

Quote:

Originally Posted by Just_Steve My last colonoscopy cost me 2 x $20 copay. I dread medicare.

What? I had two in the last 10 years (on Medicare) and because I have a Medigap policy, I paid $0.

Oh, I just had a total hip replacement in November and my cost is $0, and I got to choose the surgeon and facilities.

Medicare is the Holy Grail of medical insurance (with a suitable Medigap policy).

[Just_Steve]

Quote:

Originally Posted by travelover Why? I had a colonoscopy under Medicare and it cost me nada.

Quote:

Originally Posted by aja8888 What? I had two in the last 10 years (on Medicare) and because I have a Medigap policy, I paid $0. Oh, I just had a total hip replacement in November and my cost is $0, and I got to choose the surgeon and facilities. Medicare is the Holy Grail of medical insurance (with a suitable Medigap policy).

Reading all of the previous multi thousands of dollars colonoscopy kind of makes me nervous.

[travelover]

Quote:

Originally Posted by Just_Steve Reading all of the previous multi thousands of dollars colonoscopy kind of makes me nervous.

Having a camera shoved up my keister makes me nervous.

[Just_Steve]

Quote:

Originally Posted by travelover Having a camera shoved up my keister makes me nervous.

Having had prostate cancer a camera is the least invasive thing i have had up there

[aja8888]

One thing the ACA did for us on Medicare is it made us feel like we got the "you can choose your own doctor" plan!

[Dtail]

Quote:

Originally Posted by travelover Having a camera shoved up my keister makes me nervous.

Best 30 minute sleep you will have.

[travelover]

Quote:

Originally Posted by Dtail Best 30 minute sleep you will have.

Oh, I've had it done three times, plus a sigmoidoscopy while I was awake. What fun watching it on the monitor screen live while the medical folk rate your cleansing thoroughness.

[bingybear]

Quote:

Originally Posted by Just_Steve Reading all of the previous multi thousands of dollars colonoscopy kind of makes me nervous.

If a couple K makes you nervous, I would check if your plan.. is it realistic as you age. What is the planning number for retiree health care for a couple 65 these day? $300k or so?



Don't get me wrong, I would like to not have to spend it on non-fun stuff. But I planned to blow the MOOP a number of times. If I don't use it.... more play $

[Freedom56]

Just to note, the protocol for colonoscopy has changed at our provider at UCLA health. They now do annual stool DNA testing as part of the annual physical screening test (like Cologuard) and only subject a patient to a colonoscopy if the markers are positive for polyps and/or colon cancer. Stool DNA testing is 100% covered per the ACA. The bill for this test to the insurance company was $38 and they paid 100%. This is a far better option than subjecting yourself to a Colonoscopy (which I had at age 50).

[Teacher Terry]

Freedom, those tests only work if you don’t have hemorrhoids that occasionally bleed. I had one 11 years ago and will have one more before 70.

[Potstickers]

My understanding is that once you've had polyps, Cologuard is not approved. Also, it is a lot more than $38 -- more like $500+. $38 sounds like the price for a traditional (non-DNA) stool sample that looks for occult blood. Cologuard is not looking at occult blood, it is looking for specific DNA markers.

[RetiredAt55.5]

Quote:

Originally Posted by Potstickers My understanding is that once you've had polyps, Cologuard is not approved. Also, it is a lot more than $38 -- more like $500+. $38 sounds like the price for a traditional (non-DNA) stool sample that looks for occult blood. Cologuard is not looking at occult blood, it is looking for specific DNA markers.

This article claims the test shouldn't be used for a person with hemorrhoids http://www.cologuardtest.com/faq/hem...blood-in-stool

[RetiredAt55.5]

Interesting page on the effectiveness of Cologuard - it gave a negative result 8% of the time for test subjects that had cancer - https://www.cologuardtest.com/meet-c...e-is-cologuard

I only mention that since many stress if they don't get 100% in Firecalc.

[Freedom56]

Quote:

Originally Posted by Potstickers My understanding is that once you've had polyps, Cologuard is not approved. Also, it is a lot more than $38 -- more like $500+. $38 sounds like the price for a traditional (non-DNA) stool sample that looks for occult blood. Cologuard is not looking at occult blood, it is looking for specific DNA markers.

Looking at my EOB, the billed amount was $178 and the insurance payment was $38 and insurance adjustment was $140. An occult blood test can be purchased over the counter for much less. For example:

https://www.amazon.com/Second-Genera...7053534&sr=8-5



Cologuard would have been $420 minus the insurance adjustment and would also have been 100% covered. My doctor stated that based on the results of the last colonoscopy and family risk a stool DNA annually is a better test for my case. I contacted my insurance company ahead of my annual physical to see if these tests were covered in lieu of a colonoscopy and they stated yes.

[rodi]

I realize this is about colonoscopy covereage as a preventative procedure... but I have a similar tale for a check up.

One of my son's went in for an annual physical to get the sports physical paperwork for swim team. It had been over a year and should have been covered 100%. The doctor noted that he was on meds for depression (handled through his psychiatrist and therapist - different department) and asked him how that was going... he answered the question.

By answering that question it was coded as a follow up visit for the mental health department. I spent about 3 hours on the phone explaining that his primary was NOT the provider for his mental health care - and he did not ask the doc about the meds - she brought it up and he responded that it was 'fine'. They agreed to waive the charges *this ONE time*.

I have had discussions with both my son's that if they go in for a physical (just a regular annual physical) they need to respond to every question with "I'm on a HDHP and will this cost my mom money if I answer this?" Seems extreme - but the billing department made it clear they will not wave the fees in a future similar situation. I do consider it a valid question for a primary to ask about meds the patient is on... but don't think it's a $500 question.

The doctor needs to be fully aware that if they code something one way it can have financial impacts on the patient.

[JoeWras]

Quote:

Originally Posted by rodi The doctor needs to be fully aware that if they code something one way it can have financial impacts on the patient.

Well they are fully aware it has financial impacts on their practice or corporate incentives. And if they play dumb about insurance, then they are just dumb.

I started seeing this double billing thing about 10 years ago, right when I switched to a high deductible. My doctor's office put up big signs about this, saying they are required to do so. However, their language is more of a "request from patient" thing. I.e. doctor says: "OK, you are great. Anything else?"

You can be assured if you open your mouth after that, you will be billed a second time, even if the answer took 5 seconds.