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Colonoscopy and ACA coverage quirks and headache
Old 12-21-2019, 07:55 AM   #1
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Colonoscopy and ACA coverage quirks and headache

I thought I'd share my recent experience in case someone else is considering getting colon cancer screening done under ACA.

I have the Blue Shield Bronze plan so my annual deductible is $7550. I went in recently for my annual check up and asked my Primary Care Doc about colon cancer screening since I'm overdue by 9 years. I was hesitant to get a colonoscopy and wanted to do a stool test instead partly because I've read stories including on this forum of others getting charged several thousand dollars if polyps are found. I told my Doc that I've been buying the retail test kits available from Walgreen and they've always come back negative but I've read that they weren't that accurate. The Doc said colonoscopy is the gold standard and by far the best way to screen for colon cancer. So I relented and agreed to do a colonoscopy and accepted the fact that because I have the Bronze plan I may have to shell out several thousand dollars.

When I got home, I started researching colonoscopies and found that under ACA rules, a screening colonoscopy should be fully covered as preventive without any co-pay including removal of polyps, sedation and biopsies. However, if I had opted for a stool test and it came back positive then I would have to have a colonoscopy which then becomes a diagnostic test and my $7550 deductible would apply before any coverage kicked in. So I was happy my Doc talked me into a colonoscopy. I then called my insurance carrier and asked if removal of polyps would be covered and was told no - the insurance would only cover screening but not removal of polyps. I decided to go ahead with the procedure anyway hoping they would not find any polpys.

During the colonoscopy they found and removed 4 polyps. The bill for the procedure was over 9 thousand dollars. As expected, Blue Shield did not cover the removal of the polyps or all of the sedation and facility costs and wanted me to pay over $2000. I did some more research and found several official government documents and websites stating that everything should be covered. I called Blue Shield and told the rep that all the official documents and even a Blue Cross Blue Shield FAQ from New Mexico stated it should be fully covered. The Rep said that Blue Shield of CA is not related to New Mexico insurance plans. I responded by saying ACA applies equally to every insurance carrier. It doesn't matter if you are Blue Shield, Blue Cross, Aetna or whoever since it's a federal program and I'm pretty sure that California did not get an exception to the rules so I disagree with your denial of coverage and would like to file an appeal. After being on hold for several minutes the rep came back and said Blue Shield could do a one time exception to cover all the expenses. I said great as long as it covered all of the charges related to the colonoscopy since some of the charges had not shown up in their system yet. The rep said they would put a note in my file so that pending charges would also be covered.

Ironically, I met a Blue Cross customer service rep from another State the day after my phone call with Blue Shield and I told this rep about my encounter. The rep said that patients really need to do their homework otherwise they are liable to end up paying for services that should be covered.
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Old 12-21-2019, 08:02 AM   #2
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The polyp thing is very confusing. I've had 3 colonoscopies and two found polyps. Insurance covered it 100% despite my having a high deductible plan. I was blessed! I've since switched carriers and wonder what my future holds, since I'll probably have future polyps. (For the record: my past procedures were covered by Megacorp's good high deductible plan by UHC. My new carrier is a BC/BS plan for my DW's retirement, supposedly a good plan.) We continue to see on this forum that it is all over the place.

But what I want to say is this: you are saving your life. Absolutely get all your insurance ducks in a row first. Know your options. Know your rights.

But for God's sake, don't skip the test and potential for polyp removal!!! It can save your life. It saved mine.

I'm not saying this is your case, OP. I'm talking in general. I had friends at w*rk who would go to their Lexus dealer and drop $1500 for a brake job and not think anything of it. But when it came to some medical procedure? Hell, not going to do it unless someone else pays. That's messed up, and just another symptom of this messed up system.
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Old 12-21-2019, 08:25 AM   #3
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...But for God's sake, don't skip the test and potential for polyp removal!!! It can save your life. It saved mine...
.
Someone I worked with died of colon cancer a couple of year ago, I believe he was in his late 50's. Several years ago I was flying up to Alaska and the guy next to me said he was diagnosed with colon cancer in his 40's. He said he was shocked because he was in great shape, ex special forces and all that. He highly recommended that I get a colonoscopy. Both of these cases have been weighting on my mind for quite some time so I finally decide to go and get it done. 2 of my polyps were benign and the other 2 were tubular adenomas.
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Old 12-21-2019, 08:36 AM   #4
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I have a BC HD plan, and have my first colonoscopy coming up. I scheduled it for January, rather than at the year end, in case i have expenses from it. Also queued up my mammogram, and my knee meniscus repair. I'll come out of January poked and prodded and stitched, but might end up clearing my deductible for the first time ever.

But this is good info in case I have charges from the colonoscopy. Every time I've heard someone talk about one they had some polyps taken off, so it seems to be pretty standard.
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Old 12-21-2019, 08:56 AM   #5
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I have a BC HD plan, and have my first colonoscopy coming up. I scheduled it for January, rather than at the year end, in case i have expenses from it. Also queued up my mammogram, and my knee meniscus repair. I'll come out of January poked and prodded and stitched, but might end up clearing my deductible for the first time ever.

But this is good info in case I have charges from the colonoscopy. Every time I've heard someone talk about one they had some polyps taken off, so it seems to be pretty standard.
I had my first colonoscopy in January of 2017 when I first went on ACA plan. I am pleased to report I had no polyps found and yes it cost me $0. Good to go for 10 years and doctors office sent me a note to schedule my next one in 2027. Wishing you the best!
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Old 12-21-2019, 09:12 AM   #6
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I recently had my 2nd Cologuard experience. Came back negative. 100% covered by Bronze ACA HD plan. Easy peasy. I'm one to trust the DNA science. IMHO, yes, polyps can turn into can cancer as any cell in your body can turn into cancer. I get the removal of polyps as a safeguard. It's really a matter of opinion and comfort level.
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Old 12-21-2019, 09:12 AM   #7
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Under DHs bronze ACA plan he had a colonoscopy and there was one growth to be removed, and he was not charged extra. It was a muscle fiber growth that would never become cancerous, so he’s still on the normal 10 year screening schedule.
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Old 12-21-2019, 09:33 AM   #8
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We had a Silver Plan From Florida Blue with $149 monthly premium and $2400 Max OOP when we had our Colonoscopies, and the whole procedure for both of us was fully covered with no Copays or additional costs. I also had Cataract surgery on both eyes for $200 Copay each with no extra charges, Same for my 2 Vitrectomies. So the Silver plans worked well for us. Subsequent years with $0 premiums and $1650 Max OOP, resulted in no additional costs for either of us for any procedure we had done.
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Old 12-21-2019, 09:39 AM   #9
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Under company plans I had my first Colonoscopy. Since they found one small polyp the hole thing was diagnostic. Note this was pre-ACA. And I had to cover what the insurance didn't. I don't recall the amount I ended up paying.


So they put me on the 5 year plan.


After ACA started and when I was on cobra (corporate plan again) I investigated the cost of the colonoscopy near me. I found quite a bit of variation. I ended up paying 800 - 900 for the procedure. No polyps found.



I guess my point is ... at least for me I had a similar situation pre-ACA.


If I can gen my next colonoscopy the same year my pacemaker is changed out I should be able to group the costs and max my out of pocket.
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Old 12-21-2019, 09:52 AM   #10
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I'll share my experience. Disclaimer--we're both still covered under a mega corp plan, as still w*rking. Screening colonoscopies are considered preventive procedures and should be covered 100% unless or until they find something. In fact I called our insurance company and they told me that they are covered annually-which surprised me, since they are not recommended annually unless you have a problem.

Anyway, my husband had one in 2015 and 2 polyps were found. That turned into a diagnostic procedure, rather than preventive. However, just like any other medical procedure, we received the negotiated discounted amount and then paid our portion of deductible/co-insurance. The gross total for doctor, facility, anesthesia and lab was $6200; the bills we received totaled $476.

Fast forward to this year, he has his next one. They told us ahead of time what the estimate of our payment would be and I asked about why it was not considered preventive going in, unless they find something. They said since he had polyps last time, that will always stay in his history and the procedure will always be coded as diagnostic. This time, they found no polyps. We received bills similar to above, with the exception of the lab work. I expect this to continue for his next one. Once a polyp patient, always a polyp patient, according to them.

Meanwhile, I had mine done for the first time, no polyps were found and it must have been coded as preventive because my portion was zero.
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Old 12-21-2019, 09:57 AM   #11
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I've had two colonoscopies since going on ACA. They removed polyps and did some biopsies and I've never paid a dime.

My DS was afraid of the procedure and skipped it for years. Then they found colon cancer and now she has other fears.
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Old 12-21-2019, 10:50 AM   #12
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The logic of some of this dreck from the insurance companies never fails to amaze me.

Let's see... We'll make our member pay $1000 for a procedure known to prevent colon cancerr, that is only performed when there is a clear indication of possible cancer precursers. This may cause members to delay or skip the procedure. But we are just fine with paying $200,000 for advanced colon cancer treatment for the same member.
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Old 12-21-2019, 12:20 PM   #13
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A few things for those without experience in dealing with this...

1) If you've ever had any lower GI issues on record, it's likely you're not in for the "free" screening. And, as evidenced by the OP, be ready to fight for it. Before booking, you should have a conversation with the GI doc's billing office and get them to an unqualified agreement that they will run it through as a screening; how it's sent over to the insurance company is the deciding factor as to if it can be screening or not.

2) Get a quote. Your doctor should be able to tell you, down the last dollar, how much everything will cost. They contract with the "facilities" and the anesthetist, but they know. They might give you someone else to call, but you should know, before the procedure, exactly how much everything will cost, except there is a variable for biopsies (you may or may not have them). But you can know how much you're in for before the procedure.

2b) Don't have it done in a hospital. Besides harboring the worst antibiotic resistant bugs, if you have the procedure in the hospital, you'll be in for much more money. Five times the price is what comes to mind, but could be more.

3) The drug store test should not be compared to the DNA test (Cologard). If you want to compare anything, compare a colonoscopy (the gold standard) to the DNA test, as those two show nearly equal ability to detect cancer. The colonoscopy suffers from the ability of the doctor to visually spot things (there are lots of folds to peek behind, and doctors tend to be in a hurry these days). The DNA test can find things that can't be seen, so that is a strength. The down-side is that a positive DNA result has you doing a colonoscopy anyway.

4) The adenoma detection rate is the best quality measure that you can use to judge how well your doctor or facility does at finding cancer. Comparison shop. The measure used to be how long it took the doctor to retract the scope, which I found a bit distant to what we really want done. The ADR is much better. Ask about it.
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Old 12-21-2019, 12:20 PM   #14
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The logic of some of this dreck from the insurance companies never fails to amaze me.

Let's see... We'll make our member pay $1000 for a procedure known to prevent colon cancerr, that is only performed when there is a clear indication of possible cancer precursers. This may cause members to delay or skip the procedure. But we are just fine with paying $200,000 for advanced colon cancer treatment for the same member.
+1000. Hard to fix stupid!
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Old 12-21-2019, 12:46 PM   #15
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2b) Don't have it done in a hospital. Besides harboring the worst antibiotic resistant bugs, if you have the procedure in the hospital, you'll be in for much more money. Five times the price is what comes to mind, but could be more.
YOU NAILED IT.

A friend, who has a catastrophic plan and would pay all, went to the hospital for a colonoscopy. They asked her to sign something saying the expected expense would be $6k to $7k.

Despite all the prep work done, she walked right out. Did her homework. Maybe she is "sengsational", because this sounds familiar, or maybe seng and I know the same person. Eventually had the procedure in a standard GI clinic for about $1100, all inclusive.
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Old 12-21-2019, 01:33 PM   #16
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.............The bill for the procedure was over 9 thousand dollars. ...........
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.......... Eventually had the procedure in a standard GI clinic for about $1100, all inclusive.
This the part that drives me nuts. Granted not every colonoscopy is the same, but these price variances are insane.
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Old 12-21-2019, 01:44 PM   #17
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The logic of some of this dreck from the insurance companies never fails to amaze me.

Let's see... We'll make our member pay $1000 for a procedure known to prevent colon cancerr, that is only performed when there is a clear indication of possible cancer precursers. This may cause members to delay or skip the procedure. But we are just fine with paying $200,000 for advanced colon cancer treatment for the same member.
Because they guess that people are going to switch providers before that happens.
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Old 12-21-2019, 02:35 PM   #18
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Timely thread.
Had 2 colonoscopies so far at 50/56 y.o. Found non cancerous polyps.
Slated to take the next one in 2020 under the Florida Blue ACA plan.
Will be prepared to not get ripped off.
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Old 12-21-2019, 02:38 PM   #19
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Sounds to me that it's all over the place. I've had three colonoscopies. The first found polyps, no charge. The second required outpatient surgery to remove a growth. This year when my 5 years was up I braced for a few thousand in expenses. However even with my BCBS HDHP it was covered 100%.

During the referral process I had a lengthy discussion with the Dr office personnel. I refused to accept the paperwork until it specifically contained the phrase - preventative screening. Straight from the BCBS website for 100% coverage.

Now was I just lucky, did the DR office miscode the procedure? Who knows but I'll take it on this one.
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Old 12-21-2019, 02:53 PM   #20
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My wife just got a letter telling her it's time for her 5 year colonoscopy. She had uterine cancer 13 years ago.

She also had 3 major operations in the last year, not including 2 surgeries for cataracts. I just wish all of the doctors would promptly process billings after Medicare payments as we'd love to make the deductible and copayments for 2019 income tax purposes. Nothing worse than a doctor that's a year behind on their bookkeeping--costing patients money on income taxes.

At least what her problems are can be fixed. Hopefully we're over the top on surgeries.
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