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I Am Due For a Colonoscopy. Is it Covered?

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    Andy Cobb

    This isn't correct. Subsequent to passage of ACA, the Dept's of Health and Human Services, Labor, and Treasury issued a series of FAQ's to clarify coverage of preventive services. In general, anything that is considered as being an integral part of the service itself is also covered fully with no cost sharing. In the case of colonoscopy, the pre-surgical consult, prep, anesthesia, polyp removal and associated pathology tests should all be covered by all non-grandfathered commercial and ERISA plans (Medicare plans incur co-insurance for polyp removal).

    Q7 from May of 2015 addresses anesthesia: https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/aca_implementation_faqs26.pdf

    Qs7 and 8 from Oct 2015 address the pre-surgical consult visit and pathology on polyps that are removed during a screening colonoscopy :https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-xxix.pdf

    And Q1 from April of 2016 addresses bowel prep: https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQs-31_Final-4-20-16.pdf

    While diagnostic tests for symptomatic patients do incur cost sharing, many plans, including some Medicare Advantage plans, will also waive cost sharing for colonoscopies that are done as screening to follow up on a positive stool test (i.e.,they are considered part of the screening continuum, not diagnostic).

     

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    DEBRINAMARIA

    Thank you very much Andy Cobb. I recently went in for my first routine colonoscopy. Dr. and outpatient center were all in my network on my insurance with Cigna. I went in had it done and had 3 polyps removed. Received a bill 2 weeks later for me to pay 2,190.00 and the total for the procedure that was done in an outpatient hospital in Okaloosa county Fl. was a mind blowing $25,991.00. I was completely in shock. My insurance company sent the hospital a check for over 22,000.00. And my part is 2,190.00. I can not even believe this. And I called the place and they told me maybe there was problem with the coding. I never heard back. A week later I called back, I was  put on hold, on and on. Too long of a wait. Called again when I had more time, finally got someone and they told me the removal of the polys was the reason for the cost. I was there less than 2 hrs. Most of that time was sitting on a stretcher waiting to go in for my 20 minute procedure. They told me I still needed to pay the above. Thanks to your information I will be adding it to my claim to not pay this crazy amount. They have already been over paid by my insurance company.  They were paid enough for 5 or 6 people to have had Colonoscopies with surgery. Thanks again for this important information. 

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    Andy Cobb

    DEBRINAMARIA, I'm so sorry you're having to deal with this. $25K for a colonoscopy is ridiculous, even with polyp removal. There's no transparency into contracted rates between providers and insurance companies, but that's 10x a reasonable amount. Still, the best thing you can do is focus on the balance they are billing you.

    First, contact Cigna to address this. If you're getting this plan through your employer or on the exchange and it's not grandfathered (Cigna can tell you what kind of plan you have when you contact them), they should cover this at 100% and can help adjudicate this with the doctor's office. If that doesn't get you anywhere, you still have a couple of options.

    • If this is provided through an employer, contact the benefits department. Cite the notations from the Federal Gov't in my first comment that say this should be paid. Because they can mean thousands of policies, employers are the VIP customers of the health plan and will often be able to get this taken care of. Many even have advocate services to work directly with the insurance company and the facility on your behalf.
    • If that doesn't work, and this is a self-funded plan (or ERISA plan, meaning the employer pays all of the costs and CIGNA is just an administrator), you can file a complaint with the US Department of Labor. 
    • If this is a traditional insurance plan meaning CIGNA is actually the payer, then you can file a complaint with your state insurance commissioner.

    Hopefully you can get this addressed without getting to the last 2 points. I do think many of these cases are just miscoding and a lack of incentive for either doctor's offices or insurance companies to address the problem, rather than anyone being malicious. Unfortunately it leaves patients stuck in the middle, and the only way to really create incentive is to push back. I'm rooting for you!

     

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    Elle Navorski

    Andy Cobb, thank you especially for the link on anesthesia. I had a colonoscopy screening in November, 2019. The insurer has stated I am obliged to pay $528 for part of the anesthesia bill and anther $1200 for part of the recovery room bill. I have formally appealed to the insurer for both the anesthesia charge and the recovery room charge. I found your phrase "integral part of the service" interesting. As I bet you know, the phrase (or similar wording) appears in CMS documents but not the ACA text itself. Do you or anyone here have knowledge of the recovery room being considered an "integral part of the service" in the case of a colonoscopy? Would a doctor let a patient skip the recovery room? Of course I did not know enough to ask whether I had a choice to do so. The damned staff must have been salivating at everything they got to bill me.

    I try to keep my emotion out of my communications with the insurer and provider. If the insurer denies my appeal, then I am ready to elevate my appeal to the state insurer.

    I had a colonoscopy five years ago and paid not one dollar for it. I was led to believe that the November 2019 colonoscopy would likewise cost nothing. I am disgusted with the lack of transparency. But I admit that, with a little more enlightenment, I could have asked questions directly of the insurer.

    Lesson learned. Do not trust the medical facility, its staff, the doctor, or any vague verbiage in the insurance plan. Meanwhile, the mere fact that the insurer is billing me in part for the anesthesia (for now) tells me the company is crooked.

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