Short answer: if the colonoscopy is a screening and the provider is in network, an ACA-compliant plan has to cover it at no cost to the patient. That includes more than just the doctor's time. Where people get surprise bills is when the procedure gets billed as diagnostic instead, or when part of the care team is out of network.
What has to be covered at no cost
Non-grandfathered ACA plans, including Marketplace plans, must cover preventive services rated A or B by the U.S. Preventive Services Task Force without cost sharing when the patient uses an in-network provider. For a screening colonoscopy, federal guidance has confirmed that this covers the whole episode, not just the scope:
- The screening colonoscopy itself, for average-risk adults. The USPSTF recommends screening beginning at age 45 and continuing through 75.
- Anesthesia that is medically necessary for the procedure.
- Polyp removal and the related pathology performed during the screening. A screening does not turn into a diagnostic procedure just because something was found and removed.
- A follow-up colonoscopy after a positive stool-based test such as FIT, FOBT or a multi-target stool DNA test. Federal guidance treats that colonoscopy as an integral part of the screening, so it should carry no cost sharing.
The bowel prep kit and the facility fee are generally handled as part of the screening as well, but these are the two line items that vary most between plans. It is worth confirming both with the insurer ahead of time.
When cost sharing does apply
A colonoscopy can legitimately carry a deductible, copay or coinsurance when:
- It is diagnostic, meaning it was ordered to evaluate symptoms such as rectal bleeding, anemia, or abdominal pain rather than to screen a person with no symptoms.
- The patient is on a grandfathered plan, a short-term plan, a health care sharing ministry, or another product that is not ACA-compliant. These are not bound by the preventive-services rule.
- Part of the care was delivered out of network. The anesthesiologist or the pathologist is a common culprit, since patients rarely choose them.
- The patient is screened more often than the recommended interval because of a personal or family history that puts them in a high-risk category. Coverage here depends on plan specifics.
If a bill arrives anyway
A bill for what should have been a free screening is often a coding problem rather than a coverage problem. Steps that tend to resolve it:
- Ask the provider's billing office which CPT and diagnosis codes were submitted, and whether the visit was coded as screening or diagnostic.
- If the intent was screening, ask them to rebill with the screening code and the appropriate modifier.
- If the coding is right and the plan still applied cost sharing, appeal with the insurer and cite the preventive-services requirement.
- Call the number on the member ID card and get the answer documented, including the reference number for the call.
Before the procedure
The cheapest fix is a phone call in advance. Ask the insurer how the screening will be paid, whether every provider involved (facility, anesthesiologist, pathologist) is in network, and whether the amount changes if a polyp is found. Ask the provider's office to confirm they will bill it as a screening.
Related
- Covered Preventive Services for Adults
- American Cancer Society: insurance coverage for colorectal cancer screening
- USPSTF colorectal cancer screening recommendation
- KFF: preventive services covered by private health plans
Questions about how a specific plan handles this? Call or text (312) 726-6565 or email help@ihealthagents.com.
This article is general information, not medical or billing advice. Coverage depends on the specific plan and how the provider bills the claim.
Comments
6 comments
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).
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.
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.
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!
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.
Update, March 17, 2020:
A couple of weeks ago I went to the provider and asked for a copy of all documents that were reviewed by me and others for my November colonoscopy. The provider staff were great. One of the documents indicated that the day of the colonoscopy, the provider communicated with my insurer. In writing, the insurer's representative said there was no co-pay, no charge, nothing to be billed to the patient. A second document indicated that there might be additional charges for anesthesia and other services. But this second document had a space for the patient's (my) signature. I had not signed it, and I do not recall seeing this second document the day of my procedure or at any time. I took the copies, scanned them, and submitted them as addendums to my appeal to my insurer. Today I received a letter from my insurer saying that the insurer would be paying for all the costs of the colonoscopy (doctor's bill; recovery room; anesthesia; the whole enchilada).
This site was way helpful. Thanks in particular to Andy Cobb.
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