Colonoscopy payment

[Mulligan]

I turned 50 so that is the time for this procedure. I checked with my insurance carrier today on this as I have a $5500 deductible. Having really never used my insurance before, let me tell you the whole process is a land mine trap of "gotcha's". First of all they say it's "free". But you also have to have a consultation which is not free. Then if any polyps are found and removed it is instantly changed to a procedure and I will have to pay for the entire procedure. Of course they offer no estimate for me on this. So I look to the area for approximate costs and they can run easily over $3000 -$5000 plus the consulting fee, plus who knows if I get screwed on the anesthesiologist who may be out of network also.
I have looked on the internet and have located a colonoscopy center that charges a $950 flat rate for procedure which covers everything including polyp removal. If any are needed to be sent to pathology lab it will be a flat $150 fee also. I am considering doing this as I know up front what I am paying and won't get screwed by the land mines of physician referral, out of network people, pathology labs, consultation fees, unknown cost at location I choose, etc. Curious what others may think about my possible choice to go "on my own" with this at a fixed reasonable cost instead of risking getting poked in the rear financially after already being poked in the rear. Plus my yearly deductible expires in less than 3 months, so if something was bad, I would be facing a new deductible again quickly.


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[nwsteve]

First congrats on getting some decent data on costs--always a source of surprise, especially the out of network gotcha
Can you "qualify" the doc that will be doing the procedure? My research prior to my procedure last year indicated there were a lot of players who have completed some sort of special training but were not actual gastroenterologists. I can not find the link right now, but withdrawal rate is a major variable in the quality of the exam. When I asked for this statistic, most could not provide. Fixed rate pricing would seem to place the incentive on speed. Suggest you google colonoscopy quality and similar to get a read of what elements you might want to qualify your provider.
You do not mention family history but if you any risk, the quality of the doc may be a variable of concern. Apparently one of the problems with speed is they miss a form of polyp that lays flat against the wall of the colon. This type of polyp apparently tends to have a higher percentage of risk of cancer.
Take care
Nwsteve

[d0ug]

I would never have a colonoscopy test because you can go to the drug store and get a FIT [ fecal immunochemical test] test which is about $5 and give you nearly the same information and if worried get a ultrasound.
Andy Rooney of 60 minuets was killed by that test and he was in good health but the doctors convinced him to take the test.

[MissMolly]

I had my first one at 55 and 3 polyps were discovered (non-cancerous) so I was put on the lovely 5-year plan. The first time cost me nothing. This year was time for my 5-year check and I assumed that since it is now a procedure rather than a test that I would have to pay. But, to my surprise, it was covered 100% by my insurance. I thought that under Obamacare that first colonoscopies were now covered regardless of whether polyps are found or not. Am I wrong?

[Palmtree]

Both me and my wife have had one. Even though we were covered by insurance, both had "gotta yahs" In each case we did it in a gastro-group center that was covered by our insurance. In both of our cases there was a problem with our anesthesiologist. In my case, there was a last minute change and my guy was out of network. It took place as I was wheeled in. It took months to get my insurance to cover it. My argument was that I had cleared the anesthesiologist before then but had no influence on who actually did it once I was there.

My wife learned from my experience and verified her anesthesiologist before going under. Her problem was with billing codes. The anesthesiologist submitted his charges using a code that our insurance would not cover. It took six months to clear this up because neither side would back down or change.

[travelover]

I sent a letter to my insurer, BCBS, asking for confirmation that a colonoscopy scheduled for a month away would be covered. They didn't reply until a month after it was completed. Thankfully, it was covered. You are smart to establish the costs upfront.

[pullmyfinger]

Would it be possible to postpone the test until January, when at least if you had to pay some out of pocket it would go on next years deductible? Not that I am suggesting people postpone screenings (I am 45 and on the 5 year plan myself) but if you don't have a strong family history or symptoms maybe it would be safe to wait a few months.

My experience both as a hospital RN and as an endoscopy patient is that the sedation is provided by RNs rather than anesthesia providers. The nursing costs usually get swept into the procedure costs rather as an additional item. It would be worth verifying who will provide your sedation and monitoring.

In my state (Washington) anyone can look up provider credentials to see if they have sanctions on their license. If I am having a procedure done I like to do a quick check to make sure there is nothing glaring. Keep in mind that not having sanctions doesn't mean that one is a good provider, and that good providers can have the misfortune of a bad patient outcome and a litigious family.

I think many of us will be looking at how much it will cost to pay for our care entirely out of pocket since we don't know all the extra charges that will be the responsibility of the patient.

[JoeWras]

Mulligan: good luck with the test. You are doing right to check up front about costs.

I'm guessing that your catastrophic plan is as reasonable as it is because they are such hard-a$$es about this. (Pun intended.)

My somewhat costly catastrophic high deductible plan through my w*rk paid it all, even though polyps were found and removed. And they found a very serious polyp (highest level of benign) so I had another scope 1 year later. Although the plan says "one per 5 years", my doctor's office checked with them and since this was a follow up for someone (me) who apparently may be prone to cancer, they covered it 100%. Turns out my w*rk's plan is good, there are actual humans on the other side of the phone, and I will probably continue it when I ER, even though it is costlier than ACA plans.

Anyway, I think it is worth it, even if you have to pay. You are not Andy Rooney. You are much younger and probably not as cranky as him. You'll do fine. It may save your life like it did mine.

[Mulligan]

I guess it's pretty normal then to have problems with billing. I definitely want to be cleared, but not at the expense of being taken to the cleaners. The low cost colonoscopy has a list of surgeons and the needed qualifications to be allowed. It is located in over 50 cities. I will have to dig deeper but it appears surgeons can sign up to be involved and offer it through various locations that are approved and agree to pricing format. I do not have a family history of colon cancer and I did take the fecal test at home that Doug mentioned. I appear to have passed that fine, but of course that only detects blood not polyps. NWSteve, I read about those flat ones and according to what I have read many of these are indeed missed and the test itself is only as good as how it's interpreted.


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[Mulligan]

Quote:

Originally Posted by JoeWras Mulligan: good luck with the test. You are doing right to check up front about costs. I'm guessing that your catastrophic plan is as reasonable as it is because they are such hard-a$$es about this. (Pun intended.) My somewhat costly catastrophic high deductible plan through my w*rk paid it all, even though polyps were found and removed. And they found a very serious polyp (highest level of benign) so I had another scope 1 year later. Although the plan says "one per 5 years", my doctor's office checked with them and since this was a follow up for someone (me) who apparently may be prone to cancer, they covered it 100%. Turns out my w*rk's plan is good, there are actual humans on the other side of the phone, and I will probably continue it when I ER, even though it is costlier than ACA plans. Anyway, I think it is worth it, even if you have to pay. You are not Andy Rooney. You are much younger and probably not as cranky as him. You'll do fine. It may save your life like it did mine.

If it wasn't for the customer rep, I would be nowhere. And even then I knew some things like if they find a polyp you have to pay, he didn't mention but confirmed it when I told him I knew about that point. Finding any info at all is like searching for a needle in a haystack. No coverage books are ever sent out anymore, and good look finding anything on the website other than the basic overview of my plan. Oh and I just love the doctor and in-network provider search tool. You have to know the names and type them in to see if they are in-network. What if I don't know a name, can't your search tool provide a list for me? I thought that was what a search tool is for. Not a confirmation of what you already know.


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[truenorth418]

I had my first colonoscopy a few months ago after I turned 50. Although I had to pay for the initial consultation (about $85), the actual procedure, including the anesthesiologist, was fully covered at no additional charge to me. I didn't have an polyps or other follow ups. I would have had to pay almost $7,000 out of pocket if not for the preventive coverage benefits of Obamacare.

[Billy]

Hi Mulligan,

Congratulations on taking care of yourself. Smart move.

I would be inclined to go for the procedure where you know what you are paying up front. While it was mentioned that perhaps these people might emphasize speed rather than thoroughness, I would think that because this is the only thing they are doing, that they are skilled at it and know what to look for.

Mine is an alternative point of view. I think both have credence.

Not that this will help you decide on your immediate situation, but my husband just got a colonoscopy in Chiang Mai Thailand at a JCI accredited hospital.

He received a consultation with a real gastroenterologist, the prep medicines, anesthetic by a real anesthesiologist, recovery room, photos of his procedure and a follow up consultation all for $430USD.

The first consultation and the prep was done on Tuesday, the procedure and receiving the results and follow up consultation was done Wednesday.

We went to the cashier's desk and paid out of pocket, received our senior 20% discount and went home.

This is just FYI, as I realize most people are not inclined to do medical tourism, but it is an option. We came to Thailand to have several procedures done so we were able to group everything together and the price of the airfare was utilized to the best advantage.

Also, just FYI, I received a colonoscopy as well as an endoscopy and my bill came to $640USD.

Hope you find this information to be useful.

[savory]

This was from an earlier post - I got hit big time, $3,000, on my colonoscopy. I waited 5 years because I thought I was on a preventative 5 year plan since they found a polyp. It turns out that (unless the policy is changed), I will never qualify under preventative care. I will be considered diagnostic because of the polyp that was removed at an earlier exam. Conversations with the doctor about coding went nowhere. Same thing with the insurance company. There was no way of getting over the earlier polyp removal, which was benign. Once found, I am diagnostic care and responsible for the exam.

My policy did make progress on the removal of a polyp during the preventative exam. In this case, they no longer code it as diagnostic. This was a recent change with my UHC policy. But, once they remove the polyp, your next visit is diagnostic and the deductible at minimum will be the responsibility of the patient.

Update - I like the idea of the $950 charge. While it is a different procedure, I learned about a less expensive MRI procedure. Older equipment but good enough. For my next colonoscopy, I will look for the $950 and/or the fecal matter test.

[braumeister]

FWIW, my last colonoscopy was in 2009, and the initial billing (standard price) was:

$575 for the colonoscopy itself
$942 for the endoscopy center where it was done
$1,517 Total

With good insurance, I wound up paying just $78 but the point is that those high prices quoted here sound fishy to me.

[REWahoo]

Reading this thread makes it clear - when it comes to a colonoscopy odds are you're gonna take it in the shorts.

<whistling past the graveyard as I have one scheduled for next week...>

[RonBoyd]

Quote:

Originally Posted by d0ug I would never have a colonoscopy test because you can go to the drug store and get a FIT [ fecal immunochemical test] test which is about $5 and give you nearly the same information and if worried get a ultrasound. Andy Rooney of 60 minuets was killed by that test and he was in good health but the doctors convinced him to take the test.

I am not medically trained (or for that matter, very knowledgeable in that area) but isn't the "real" purpose of a colonoscopy to discover polyps before they become cancerous (and, hopefully, prior to metastasizing). I was under the impression that the FIT would give a post cancer diagnosis. I am further confused on the use of ultrasound -- removal of any polyp would require the Colonoscopy anyway; doubling (well, increasing) the cost.

[Tailgate]

Good luck... I think I would go for the out of network fixed price place. Just make sure you prepare your battle station for the day before...

[MichaelB]

ACA compliant plans must include polyp removal as part of the screening, which is an essential health benefit and not billable to the patient. Non-compliant plans are free to deal with this as they wish, and do so.

When a polyp is found, most practicioners prescribe repeat colonoscopy in 5 years or so, and apparently some insurers are now classifying those as billable procedures. Medicare also does not classify polyp removal as part of the screening.

A couple of links with more detail

http://kaiserfamilyfoundation.files....e-care-act.pdf
ACA: When Is a Screening Not a Screening?

Good luck Mulligan and REWahoo

[athena53]

Thanks for this topic. I'm due for a 5-year check next year and this will be my first time with a private HDHP; good to know what to expect and what questions to ask. I'm happy to see that my doc and the hospital I used in the past are in network, but with a couple of (benign) polyps in my history, I'm going to check on costs and coverage.

Quote:

Originally Posted by davef Update - I like the idea of the $950 charge. While it is a different procedure, I learned about a less expensive MRI procedure. Older equipment but good enough. For my next colonoscopy, I will look for the $950 and/or the fecal matter test.

I did the Fecal Occult Blood Test a few months ago just to get an indication as to whether there might be problems developing. It was negative, so that was happy news. (I'm not a doctor but my understanding is that it's just that- an indication. A positive result was what motivated me to get my first colonoscopy and I did have a polyp that was removed.)

The MRI procedure (again, my non-expert understanding) may find polyps but (1) you still need to do the same prep, which for most people is the worst part and (2) if they find anything you need to go back for a regular colonoscopy to get it removed.

[Mulligan]

Quote:

Originally Posted by MichaelB ACA compliant plans must include polyp removal as part of the screening, which is an essential health benefit and not billable to the patient. Non-compliant plans are free to deal with this as they wish, and do so. When a polyp is found, most practicioners prescribe repeat colonoscopy in 5 years or so, and apparently some insurers are now classifying those as billable procedures. Medicare also does not classify polyp removal as part of the screening. A couple of links with more detail http://kaiserfamilyfoundation.files....e-care-act.pdf ACA: When Is a Screening Not a Screening? Good luck Mulligan and REWahoo

One of your links below Michael summarized the gotcha game going on. I purchased my policy last year, though underwritten is still part of ACA guidelines. My provider is obviously still playing hardball. I think my game plan will be visit my doctor for my annual physical (which for me means about every 20 months) and get a referral to the $950 place and wait until after November 30 as that is when the deductible starts again. It might just be me, but I would rather pay that fee, instead of getting hopes up for a free one, then get caught in a battle over who will pay. I may be a bit odd, but I am the type of person who can occasionally spend $100 needlessly, but screw me over $5 really ticks me off, ala cable billing!

In February, the Obama administration overruled that interpretation, holding that the patient doesn't have to pay a cost share when a polyp is found. "Polyp removal is an integral part of a colonoscopy," the Department of Labor stated.

But this ruling did not stop insurers from finding new ways to impose a cost share. While many payers waive the cost share without quibbling, many others still make stipulations, says Amy Fasti, vice president of billing services at Physicians Endoscopy, an operator of endoscopy centers based in Jamison, Penn.

"It feels like a game sometimes," Fasti says. When a cost share is imposed, billing staff has to appeal the denial and discuss the law with the recalcitrant payer. In many cases, she says, the appeal is successful, but it takes a lot of work.

For example, when a polyp is found, insurers are now charging the patient for the next colonoscopy, arguing that the patient is no longer symptom-free and the colonoscopy has become a "diagnostic" or "surveillance" procedure.


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