Issues regarding colonoscopy coverage under the PPACA

[MichaelB]

The Kaiser Family Foundation just published an interesting analysis of colonoscopy billing issues under the PPACA. Colonoscopies are one of the preventive screenings that are supposed to be covered without copay, deductible or any cost sharing. People take the test and in some cases are still being required to pay. This paper (here) explains what and why.

In summary, it breaks down the cases where unexpected billing occurs to three categories: 1) when a polyp is detected and removed during a screening colonoscopy; 2) when a colonoscopy is performed as part of a two-step screening process following a positive stool blood test; and 3) when the individual is at increased risk for colorectal cancer and may receive earlier or more frequent screening compared with average risk adults. It then attributes the billing to two causes: 1) how the insurance companies interpret and implement the PPACA mandate and 2) how the doctor or service provider codes the procedure.

The charges here can be substantial, and similar confusion could be expected from other preventive screenings. Some insurance companies appear to follow very narrow interpretations and their users may face more unexpected costs.

 

[braumeister]

More profit for colonoscopy centers?
Sounds like things are looking up.

 

[grasshopper]

I think colonoscopy is like going to the dermatologist or the auto mechanic, they can always find something to fix, or slice away. I never get out without being billed for something.

 

[JoeWras]

Thanks for the information. I'm scheduled next year, and I'm on a high deductible plan, so this is timely info.

 

[savory]

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.

 

[Alan]

Thanks for the link Michael. Sounds a colonoscopy can be a pain in the a$$ in more ways than one

 

[rodi]

Wow.
It's not like people are looking for excuses to do extra colonoscopies.... Looking for freebies.

In fact it's probably one of the least favorite medical procedures for most people.

I have Kaiser Permanente - so the charges are a non issue for me. But when I ER - we'll be on a high deductible plan most likely - so this could be an issue. And if my future insurance acts like Davef's insurance, I'm doomed. I've had polyps removed.

 

[packrat44]

In fact it's probably one of the least favorite medical procedures for most people.

.

I have had 3 colonoscopies and did not find any to be a pain in the @ss (other than the prep). However, the needle biopsy which I had for prostate cancer (and will have to continue annually due to a positive reading) is definitely unpleasant.

 

[kaneohe]

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.

but diagnostics are covered , right? Only a problem if you have a high deductible? or not?

 

[foxfirev5]

I think colonoscopy is like going to the dermatologist or the auto mechanic, they can always find something to fix, or slice away. I never get out without being billed for something.

Boy, if that's not the truth

 

[JoeWras]

Thanks for the information. I'm scheduled next year, and I'm on a high deductible plan, so this is timely info.

We're about to find out what my HD plan is going to do with this. I realize it isn't PPACA yet, but it is interesting to see how various insurances are handling this.

Just had this potentially lifesaving procedure recently, and a biopsy was taken. I'm going to find out what the bills are even though I was due for screening, but also went down one of the diagnostic paths.

Additionally, I'm going to have to do this on a recurrent basis now, so I'll have to consider changing my insurance. But I still like the HD plans with an HSA. We'll see, I'll have some math to do.

PS: if you are 50 or older and haven't had your colonoscopy yet, drop everything and schedule it now. It was not bad. I don't know what people are talking about with prep. It wasn't pleasant, but it wasn't bad. I just didn't like the day of clear liquid diet of broth and honey. So what, I dealt with it. Good discipline. And doc gave me an A+ for preparation.

And if you are a super LBYMer (see the recent "can I ER under 500k" thread), well, I don't know what to say, but you need the screening too, even if you are going to the clinic or whatever. Find a way. Your life may depend on it.

 

[sengsational]

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 if you had one,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.

I had the same thing happen trying to talk about coding the procedure as diagnostic. We've fallen off the preventive wagon, and once off, you can never (apparently) get back on.

So this would not work for us, but what if someone that's doing their first one at 50 goes in with specific instructions NOT to remove polyps? True, you'd need yet another colonoscopy to remove the polyp if you had one, but you could go on vacation to Panama, with world-class healthcare, and get it done there, without insurance, and come out much cheaper. Just an extra day of "prep" might not be worth the $3000, hehe

 

[travelover]

I think colonoscopy is like going to the dermatologist or the auto mechanic, they can always find something to fix, or slice away. I never get out without being billed for something.

Amen re the dermatologist. I paid the PA to cut off a tiny mole, paid even more for the lab to make sure it wasn't cancerous (PA said it was low risk) and paid even more yet for the physician to evaluate the lab report. $500 mole.

 

[JoeWras]

Amen re the dermatologist. I paid the PA to cut off a tiny mole, paid even more for the lab to make sure it wasn't cancerous (PA said it was low risk) and paid even more yet for the physician to evaluate the lab report. $500 mole.

Yeah, and my colonoscopy is probably going to put me out $3k. And probably the same every 3 to 5 years from now on.

The thing is I've seen young (about 50 y.o.) friends die from both colon cancer and melanoma. Friends, I'll pay the money...

As for our health care system, the problem is complex. I don't know how to fix it. I just know that that $3k may have just saved my life.

So, this is why many of us are planning for $20k for 2 people per year. I congratulate those who have managed extreme low costs through various measures. All I'm saying is don't cheat yourself, please!

 

[Texas Proud]

It is interesting about billing...

I talked to my insurance company about it and was told that it is covered... but that docs (as many here mentioned) find polyps and then codes the whole procedure differently...

She said to have the doc code the colonoscopy as preventative and the polyps at whatever they need to do... the colonoscopy would be covered, but not the rest...

She did say that not all docs would take the time to do it right....

 

[MichaelB]

We're about to find out what my HD plan is going to do with this. I realize it isn't PPACA yet, but it is interesting to see how various insurances are handling this.

Just had this potentially lifesaving procedure recently, and a biopsy was taken. I'm going to find out what the bills are even though I was due for screening, but also went down one of the diagnostic paths.

Additionally, I'm going to have to do this on a recurrent basis now, so I'll have to consider changing my insurance. But I still like the HD plans with an HSA. We'll see, I'll have some math to do.

PS: if you are 50 or older and haven't had your colonoscopy yet, drop everything and schedule it now. It was not bad. I don't know what people are talking about with prep. It wasn't pleasant, but it wasn't bad. I just didn't like the day of clear liquid diet of broth and honey. So what, I dealt with it. Good discipline. And doc gave me an A+ for preparation.

And if you are a super LBYMer (see the recent "can I ER under 500k" thread), well, I don't know what to say, but you need the screening too, even if you are going to the clinic or whatever. Find a way. Your life may depend on it.

Sounds like the colonoscopy was the right choice. Good news.

If the health care plan is grandfathered it is free to treat the polyp removal as a separate charge as long as that was the practice in 2010. If it is subject to the new essential health benefit regs it must treat the removal as part of the essential benefit and cannot require additional cost share. See the DOL FAQ here http://www.dol.gov/ebsa/faqs/faq-aca12.html

Q5: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the USPSTF recommendation, is it permissible for a plan or issuer to impose cost-sharing for the cost of a polyp removal during the colonoscopy?

No. Based on clinical practice and comments received from the American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and the Society for Gastroenterology Nurses and Associates, polyp removal is an integral part of a colonoscopy. Accordingly, the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure. On the other hand, a plan or issuer may impose cost-sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.

 

[travelover]

......... I just know that that $3k may have just saved my life...........

That's a good attitude. Maybe the next time they will charge you $10,000 but it will still be bargain because it might save your life.

 

[Mulligan]

That's a good attitude. Maybe the next time they will charge you $10,000 but it will still be bargain because it might save your life.

Hmmm, my money or my life...I am glad I haven't crossed that bridge yet. Although I hope I get to the point where I quit doing what I have done my whole life which is ignore the problem and it will go away (and it has). I will do the colonoscopy at 50, though it will be a week before I turn 51. But that prostate exam isn't going to happen.

 

[travelover]

Hmmm, my money or my life...I am glad I haven't crossed that bridge yet. Although I hope I get to the point where I quit doing what I have done my whole life which is ignore the problem and it will go away (and it has). I will do the colonoscopy at 50, though it will be a week before I turn 51. But that prostate exam isn't going to happen.

Sorry, I guess I was unclear. The whole reason that medical care costs what it does is because when you are talking about dying, no amount is too much. That provides a huge opportunity for abuse.

 

[JoeWras]

Sorry, I guess I was unclear. The whole reason that medical care costs what it does is because when you are talking about dying, no amount is too much. That provides a huge opportunity for abuse.

Yeah, I got it.

My deductible is $4k, so $10k won't apply for me. For Mulligan... it is different. I think his is real high.

It doesn't matter what I pay. Someone pays, and that's where the abuse is happening. But abuse is a relative term since there are so many players in this crazy process (doctors, insurance, lawyers and government).

P.S. To be clear, I don't think polyp removal is abuse. Now if you talk about the charge for it, yeah, I get it.

 

[Mulligan]

Yeah, I got it.

My deductible is $4k, so $10k won't apply for me. For Mulligan... it is different. I think his is real high.

It doesn't matter what I pay. Someone pays, and that's where the abuse is happening. But abuse is a relative term since there are so many players in this crazy process (doctors, insurance, lawyers and government).

P.S. To be clear, I don't think polyp removal is abuse. Now if you talk about the charge for it, yeah, I get it.

Joe, one thing is for sure which I have learned through this forum, is on top of all of it now, you have to be an expert in understanding billing coding. I will have to make sure I know the right questions to ask and prove they answered them correctly. Punching in an unfavorable code, can evidently hit a person in the wallet hard.

 

[JoeWras]

Joe, one thing is for sure which I have learned through this forum, is on top of all of it now, you have to be an expert in understanding billing coding. I will have to make sure I know the right questions to ask and prove they answered them correctly. Punching in an unfavorable code, can evidently hit a person in the wallet hard.

Thanks. You know, I've read about the code thing here and elsewhere on this board, and forgot about once I was in the office. Well, it had a passing thought, but I let it go figuring I could worry later. My focus was on the doc and the issues at hand.

However, I probably should have brought up the billing ahead of time. Now I have to wrangle with this post-billing and that's hard.

Got to keep this in mind for the next procedure, but it is so darn hard. I worked in medical billing in the early 80's and it was tough then. (I was the guy on the other side of the phone getting yelled at.) It has just gotten worse and worse and what I did then does not really apply to today's madness.

 

[Mulligan]

Thanks. You know, I've read about the code thing here and elsewhere on this board, and forgot about once I was in the office. Well, it had a passing thought, but I let it go figuring I could worry later. My focus was on the doc and the issues at hand.

However, I probably should have brought up the billing ahead of time. Now I have to wrangle with this post-billing and that's hard.

Got to keep this in mind for the next procedure, but it is so darn hard. I worked in medical billing in the early 80's and it was tough then. (I was the guy on the other side of the phone getting yelled at.) It has just gotten worse and worse and what I did then does not really apply to today's madness.

I agree, as I basically handled it the way you did a couple months ago when I went in for my annual physical that was three years late. My doctor works at a hospital facility and just sent me downstairs to do the blood work. All the way down I was thinking I am going to get screwed on this. I should go to an offsite facility somewhere. But l just kept walking toward the directed site like drone because it was too convenient. The bill was a little over a $100, which I guess wasn't too bad, except I did it on my own at a health fair at a nearby hospital a year ago for $10 that spit out the same results....Then I have read recently about concierge doctors bragging about getting their patients cholesterol checked for $3 by bypassing all the middlemen and paperwork costs....

 

[imoldernu]

If we can learn one thing from Michael's initial post, it may be that we should do a lot of research before undergoing any kind of test or procedure.

The link to the PPACA information points up the reason that Healthcare is a 24,000 page package, and reading the "specifics" is so important. Naturally no one will ever "know" what's in the healthcare laws, but when it comes to the details, the time spent "Googling" the details, could pay off big time.

As a colon cancer survivor, this particular issue is very interesting.

We begin everything that has to do with health... by researching on-line. Before a doctor visit for any reason, we spend as much time as necessary (hours sometimes) researching the reason(s) we're looking for help. No one knows your body better than you do, so looking up symptoms, or following through on suspicions online, gives the doctor a jump start, and saves time.

Researching procedure costs by searching "cost of lumpectomy" (for instance) often brings up interesting results, such as whether a procedure or test can be done in a clinic or as an outpatient.

The maze of government regulations is usually there for a reason. Without regulation we are all subject to being overcharged. Those who suggest that regulation is always "too much" should consider what living in an uncontrolled society might be. We have a chance of staying ahead of the game, by looking before we spend.

 

[killingme]

imoldernu- I might agree with that but a procedure which cost me nothing before, when market factors ruled the pricing structure now will cost me a substantial amount. IMO the government seems incapable of simplifying anything but constantly adds overhead to the cost. Insurance companies are for profit entities and as such, if you take away one revenue stream they will find another. It might be my libertarian bent, but this ride is going to be far bumpier than anyone wants to admit.

Mulligan - the concierge doctors are going to be a big part the health care of the future. My own doctors are saying they may change to a pay up front though they will help with getting reimbursement for me. SO now I can deal with the Insurance and federal bureaucracy.