Colonoscopy and ACA coverage quirks and headache

[Just_Steve]

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

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]

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]

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]

Having a camera shoved up my keister makes me nervous.

Best 30 minute sleep you will have.

 

[travelover]

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]

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]

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/hemorrhoids-menstrual-period-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-cologuard/how-effective-is-cologuard

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

 

[Freedom56]

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-Gener...keywords=stool+dna+test&qid=1577053534&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]

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.

 

[zinger1457]

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

It's been 3 years in a row that my doctors office has coded the lab blood test for the annual checkup incorrectly, even when I've reminded them the last 2 years to make sure and code it as preventive. Not big $ amounts but irritating enough to make me start looking at switching doctors.

 

[Taxman59]

Just saw the headline of this thread, and I thought "If he got a headache from the colonoscopy, it went in too far!"

 

[Splash]

Had 1st colonoscopy at 50, no polyps, covered 100% as preventive, and told next one to be scheduled at 60.

Changed doctors at 56. New doctor informed me I was late for my colonoscopy. Since mom was a colon cancer survivor, I should be on a 5 year plan. Clinic and insurance said the procedure would be considered diagnostic due to family history. Paid to have the procedure done, again no polyps. Months later I received a refund from the clinic as insurance paid the bill.

I've had similar experiences with mammograms as a 7 year breast cancer survivor. I do my best to get the provider to code my procedures as preventive. Not always successful, but that seems to be the only influence I have on the outcome.

 

[FIREd_2015]

Just saw the headline of this thread, and I thought "If he got a headache from the colonoscopy, it went in too far!"

Ha! The headache was from dealing with the clinic and insurance. The procedure took about half hour. Dealing with the clinic and insurance took another 2-3 hrs. Researching what my rights were took 5-6 hrs. Too bad I can't bill the insurance company for my time since I was doing their job for them.

Anyone hesitant to getting a colonoscopy, I'd suggest watching the Katie Couric video and others that are available online. Couple of things I learned from the videos that they don't tell you:

(1) A lot of people complain about the taste of the prep. Some can't handle the taste and throw it all up. Put it in the frig and add refrigerated cold water to it. It makes it more palatable. I had no problems when I did this.

(2) You can choose to have full sedation, minimal sedation or no sedation. I went with minimal sedation so I could watch the monitor and see the procedure. (The nurse anesthetist was standing by in case I needed more sedation.) If I had opted for no sedation then I could have driven home on my own. Might go with no sedation next time since it was pretty straight forward. Saw a couple of videos on youtube of gastroenterologist getting it done without sedation.

(2) Some docs use air to inflate your colon, others use CO2 or warm water. Ask for CO2 or water. CO2 is readily absorbed so you don't end up feeling bloated or getting cramps.

 

[meleana]

We have employer high deductible health insurance.Hubby 's premiums were free and mine were minimal.



First time years ago was a screening and we paid nothing. Polyps were found, though. Then we were supposed to come back in 5 years. I came back in 7 and hubby in 5. Now it was considered diagnostic. Both had polyps. Had to come back in 3 years. Then I had to come back in 1 year and I just had one again and I still have to come back in one year. (doesn't sound good for me)



Hubby- no. He had polyps but he can come back in 3 years.


All these times we had to pay about $1200+ each between the doc consult office visit,the procedure itself, the anesthesia, the polyp removal, the biopsy.


Now that hubby will be on Medicare Plan G I am not sure what will be covered. I will be on that same employer high deductible plan through COBRA - but this time will be paying a very high premium every month PLUS the high deductible. SMH....

 

[trumpeting_angel]

A good experience

Now that hubby will be on Medicare Plan G I am not sure what will be covered. .

Of course I have no idea what your experience will be, but I'm on Medicare with a Plan G supplement, and my recent colonoscopy cost me nothing, as my deductible was already met.



I don't know how they are coding my colonoscopies. I have a family history, and a remote personal history of IBS, although that might not be on any record that is being perused. Since everyone in my family has died of cancer, and my mother of colon cancer, I would pay for the procedure if I had to. Scary stuff. All of my colonoscopies have come up clean, though!

 

[Retired Expat]

Not under ACÁ as I reside mostly outside the country. Last year when I went for my first Colonoscopy I compared prices between here in a Good hospital in a Uruguay versus my gastroenterologist in NYC who does them in his office. List prices are outrageous but if you explain you are self insured paying cash, prices go way down. At the time I was mostly carrying major medical with a wellness package but no outpatient.

Doctor in NY offered to do it for $1000 plus $250 for the anesthesialogist. 7 polyps and questionable lesions removed no extra charge. Bill from the lab was $1,250 also. Explained my situation to the billing clerk at the biopsy lab who spoke to her supervisor. I offered to give them my credit card right then so they cut the charge in half. Less than they would collect from an insurance carrier months from then and after spending hours filing forms.

My wellness policy paid about $500 for the testing.. my $750 out of pocket is so much less than what I would have paid had I gone through insurance. It was my first real claim all year and would have all been on me and my deductible.

Since that lesson, I always ask the doctors what the charge will be if I pay cash. It is usually a much better deal and I am still free to submit the bills directly to the international insurance carrier for reimbursement.

YMMV but it works great for me and has saved a small fortune as generally in very good health and don’t run to the doctor often.

 

[JoeWras]

I don't know how they are coding my colonoscopies.

But the office does, and they are doing it right.

My GI doc's office has it together. They asked me a bunch of insurance questions and then had to delay the colonoscopy last time to go over things with them ahead of time to assure me I was properly covered.

This experience of proper coding and insurance check is not universal.

 

[Scuba]

DH had a colonoscopy this year. We tried very hard to be proactive and compare the cash vs insurance payment options up front. After many hours on the phone with both the doc’s office and the insurance company, we gave up and just had them bill insurance. It was very frustrating that no one would/could explain all the charges up front and quote us a cash price and an insurance price so we could make an informed decision. DH and I are both well educated and I was a CFO in my prior life. It is ridiculous that we couldn’t get this information up front.

 

[JoeWras]

It is ridiculous that we couldn’t get this information up front.

This theme is growing stronger and stronger on many fronts. Yes, it is ridiculous.