The skeptical cardiologist has been evaluating how much he would pay under his new, high-deductible insurance plan for a recommended colonoscopy. This is not a simple or straightforward process.
Cigna has an online tool that lets me get an estimate of what I will pay for a procedure or drug. When I entered “diagnostic colonoscopy” into the tool 137 in-network providers were listed near my Clayton, MO residence. My estimated cost ranged from $832 to $3120 depending on the provider.
The most expensive charge was $5057.
This variation in cost exists without rhyme or reason. Given that most patients have no idea of how to estimate the safety or accuracy of a colonoscopy provider, these price differences are not related to quality factors and value cannot be ascertained.
To further add to the confusion, if the colonoscopy is considered “preventive” it most likely will cost nothing. However, the coding of the procedure as diagnostic or preventive is entirely up to the whims of the facility where it is performed.
Kaiser Health News recently published the following article, outlining in detail one woman’s adventure in the land of colonoscopy pricing.
Her First Colonoscopy Cost Her $0. Her Second Cost $2,185. Why?
Elizabeth Melville and her husband are gradually hiking all 48 mountain peaks that top 4,000 feet in New Hampshire.
“I want to do everything I can to stay healthy so that I can be skiing and hiking into my 80s — hopefully even 90s!” said the 59-year-old part-time ski instructor who lives in the vacation town of Sunapee.
So when her primary care doctor suggested she be screened for colorectal cancer in September, Melville dutifully prepped for her colonoscopy and went to New London Hospital’s outpatient department for the zero-cost procedure.
Typically, screening colonoscopies are scheduled every 10 years starting at age 45. But more frequent screenings are often recommended for people with a history of polyps, since polyps can be a precursor to malignancy. Melville had had a benign polyp removed during a colonoscopy nearly six years earlier.
Melville’s second test was similar to her first one: normal, except for one small polyp that the gastroenterologist snipped out while she was sedated. It too was benign. So she thought she was done with many patients’ least favorite medical obligation for several years.
Then the bill came.
The Patient: Elizabeth Melville, 59, who is covered under a Cigna health plan that her husband gets through his employer. It has a $2,500 individual deductible and 30% coinsurance.
Medical Service: A screening colonoscopy, including removal of a benign polyp.
Service Provider: New London Hospital, a 25-bed facility in New London, New Hampshire. It is part of the Dartmouth Health system, a nonprofit academic medical center and regional network of five hospitals and more than 24 clinics with nearly $3 billion in annual revenue.
Total Bill: $10,329 for the procedure, anesthesiologist, and gastroenterologist. Cigna’s negotiated rate was $4,144, and Melville’s share under her insurance was $2,185.
What Gives: The Affordable Care Act made preventive health care such as mammograms and colonoscopies free of charge to patients without cost sharing. But there is wiggle room about when a procedure was done for screening purposes, versus for a diagnosis. And often the doctors and hospitals are the ones who decide when those categories shift and a patient can be charged — but those decisions often are debatable.
Getting screened regularly for colorectal cancer is one of the most effective tools people have for preventing it. Screening colonoscopies reduce the relative risk of getting colorectal cancer by 52% and the risk of dying from it by 62%, according to a recent analysis of published studies.
The U.S. Preventive Services Task Force, a nonpartisan group of medical experts, recommends regular colorectal cancer screening for average-risk people from ages 45 to 75.
Colonoscopies can be classified as for screening or for diagnosis. How they are classified makes all the difference for patients’ out-of-pocket costs. The former generally incurs no cost to patients under the ACA; the latter can generate bills.
The Centers for Medicare & Medicaid Services has clarified repeatedly over the years that under the preventive services provisions of the ACA, removal of a polyp during a screening colonoscopy is considered an integral part of the procedure and should not change patients’ cost-sharing obligations.
After all, that’s the whole point of screening — to figure out whether polyps contain cancer, they must be removed and examined by a pathologist.
Many people may face this situation. More than 40% of people over 50 have precancerous polyps in the colon, according to the American Society for Gastrointestinal Endoscopy.
Someone whose cancer risk is above average may face higher bills and not be protected by the law, said Anna Howard, a policy principal at the American Cancer Society’s Cancer Action Network.
Having a family history of colon cancer or a personal history of polyps raises someone’s risk profile, and insurers and providers could impose charges based on that. “Right from the start, [the colonoscopy] could be considered diagnostic,” Howard said.
In addition, getting a screening colonoscopy sooner than the recommended 10-year interval, as Melville did, could open someone up to cost-sharing charges, Howard said.
Coincidentally, Melville’s 61-year-old husband had a screening colonoscopy at the same facility with the same doctor a week after she had her procedure. Despite his family history of colon cancer and a previous colonoscopy just five years earlier because of his elevated risk, her husband wasn’t charged anything for the test. The key difference between the two experiences: Melville’s husband didn’t have a polyp removed.
Resolution: When Melville received notices about owing $2,185, she initially thought it must be a mistake. She hadn’t owed anything after her first colonoscopy. But when she called, a Cigna representative told her the hospital had changed the billing code for her procedure from screening to diagnostic. A call to the Dartmouth Health billing department confirmed that explanation: She was told she was billed because she’d had a polyp removed — making the procedure no longer preventive.
During a subsequent three-way call that Melville had with representatives from both the health system and Cigna, the Dartmouth Health staffer reiterated that position, Melville said. “[She] was very firm with the decision that once a polyp is found, the whole procedure changes from screening to diagnostic,” she said.
Dartmouth Health declined to discuss Melville’s case with KHN even though she gave her permission for it to do so.
After KHN’s inquiry, Melville was contacted by Joshua Compton of Conifer Health Solutions on behalf of Dartmouth Health. Compton said the diagnosis codes had inadvertently been dropped from the system and that Melville’s claim was being reprocessed, Melville said.
Cigna also researched the claim after being contacted by KHN. Justine Sessions, a Cigna spokesperson, provided this statement: “This issue was swiftly resolved as soon as we learned that the provider submitted the claim incorrectly. We have reprocessed the claim and Ms. Melville will not be responsible for any out of pocket costs.”
The Takeaway: Melville didn’t expect to be billed for this procedure. It seemed exactly like her first colonoscopy, nearly six years earlier, when she had not been charged for a polyp removal.
But before getting an elective procedure like a cancer screening, it’s always a good idea to try to suss out any coverage minefields, Howard said. Remind your provider that the government’s interpretation of the ACA requires that colonoscopies be regarded as a screening even if a polyp is removed.
“Contact the insurer prior to the colonoscopy and say, ‘Hey, I just want to understand what the coverage limitations are and what my out-of-pocket costs might be,’” Howard said. Billing from an anesthesiologist — who merely delivers a dose of sedative — can also become an issue in screening colonoscopies. Ask whether the anesthesiologist is in-network.
Be aware that doctors and hospitals are required to give good faith estimates of patients’ expected costs before planned procedures under the No Surprises Act, which took effect this year.
Take the time to read through any paperwork you must sign, and have your antennae up for problems. And, importantly, ask to see documents ahead of time.
Melville said that a health system billing representative told her that among the papers she signed at the hospital on the day of her procedure was one saying that if a polyp was discovered, the procedure would become diagnostic.
Melville no longer has the paperwork, but if Dartmouth Health did have her sign such a document, it would likely be in violation of the ACA. However, “there’s very little, if any, direct federal oversight or enforcement” of the law’s preventive services requirements, said Karen Pollitz, a senior fellow at KFF.
In a statement describing New London Hospital’s general practices, spokesperson Timothy Lund said: “Our physicians discuss the possibility of the procedure progressing from a screening colonoscopy to a diagnostic colonoscopy as part of the informed consent process. Patients sign the consent document after listening to these details, understanding the risks, and having all of their questions answered by the physician providing the care.”
To patients like Melville, that doesn’t seem quite fair, though. She said, “I still feel asking anyone who has just prepped for a colonoscopy to process those choices, ask questions, and potentially say ‘no thank you’ to the whole thing is not reasonable.
Some take-home points from the skeptical cardiologist:
- Always investigate alternatives for any medical procedure recommended to you. This includes alternative sites/providers for the procedure which offer transparent pricing and some evidence of high-quality work.
- Alternatives to colonoscopy for screening for colorectal cancer (CRC) include Cologuard, FOBT and virtual CT colonoscopy. All of these are considered acceptable according to the latest US Preventive Services Task Force report which recommends some type of CRC screening in adults aged 45-75 years
- Don’t just pay a medical bill that seems inordinately high. Investigate. Challenge errors.Send it to Kaiser Health News to be their bill of the month. Question.
Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with them? Tell them about it!
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
22 thoughts on “How Much Should a Colonoscopy Cost?”
I’ve had four colonoscopies in the last two months, had five polyps removed, one was pre-cancerous, three benign, one was cancerous. Followed by double CT scan to check for metastaisis, caught early, so none. Offered an operation to remove part of colon where cancerous polyp had been in order to prevent any spread to nearby lymph nodes. The chances of this were about 3%, decided against it. Total cost: nothing. UK’s National Health Service.
That sounds like an excellent system. We hear about delays in procedures in countries with single payor/universal coverage. Did you note any with your colonoscopies? Also, did you have a separate anesthesiologist on the case?
Two day wait for the colonoscopies. Two week wait for CT scan.
I have had three colonoscopies. With the first two I had polyps. They made it very clear that if they found anything I would have to pay. The third colonoscopy was polyp free so I don’t need to have another one for 5 years.
I was prescribed Suprep as part of the colon prep each time. Suprep tastes awful. This last time my insurance wouldn’t cover the cost, it was $120.
I’m not familiar with Suprep but it claims to be the #1 “branded” bowel prep for colonoscopy. (http://www.suprepkit.com)
Branded=extra cost so likely there are generic cheaper alternatives your insurance prefered.
It seems like every center has its own favored bowel prep. Given the bowel prep is the worst part of the whole procedure finding one you like is essential.
After my first “screening” colonoscopy (which was no-cost under ACA) found a polyp, every colonoscopy after that was considered diagnostic — and they were scheduled more frequently because of the polyps also. My High deductible plan (all I can get in my state as an individual) means that I pay for the whole thing out of pocket, and they told me there was NO WAY to determine in advance if anesthesia would be in-network! I finally decided that even given the size/frequency of polyps, they were all benign and I’m going back to the less frequent schedule (which will at least put me under medicare — assuming we still have it — for the next one). I am truly tired of political bandaid fixes for such a horrible system.
It is a crazy, confusing system for those who don’t have a Cadillac health care plan (the type that one typically gets if working for a health care system)
In addition, you don’t really need a separate anesthesia/anesthesiologist charge. Most of these screening colonoscopies can be done with conscious sedation under the guidance of the operator. This is how the vast majority of the endoscopic transesophageal echocardiograms are performed.
You visit a doctor for annual wellness. The doctor says it’s time for a screening for x. Your hypochondriac mind thinks up all the recent, might be related sensations and you discuss x a bit. Unknown to you, the doctor codes the screening as diagnostic and you are going to pay for that “discuss with your doctor if ___ is right for you” of all the TV ads. The doctor is just trying to be helpful and put your mind at peace.
I have a history of achalasia, and occasionally experience brief blockages. The slow emptying of the throat sometimes causes indigestion. Given the increased incidence of cancer from chronic indigestion and in chronic achalasia, I have to decide about discussing this with my gastro when I go in for the 10 yr screening colonoscopy prep meeting this week. I wouldn’t mind a “screening endoscopy with my screening colonoscopy”, but do not want to do anything to turn screening into diagnostic for either procedure.
(69 year old “healthy” worrier)
Dr. Pearson, thank you so much for mentioning the alternatives to colonoscopy. Cologuard has been my screening of choice. My doctor would prefer I go with colonoscopies (he claimed they’re the “gold standard”) but I just don’t see the justification for the associated cost, discomfort, and risk. If a definitive study exists that would indicate that I change my choice in this regard, I would consider doing so.
In the Canadian system (at least in BC), FOBT screening (which is easy and inexpensive, no bowel prep required) is covered by the provincial health plan — no cost to the patient. If — for some reason — you want a colonoscopy instead, you’ll have to justify to your GP why the extra cost would be worthwhile. The Canadian system isn’t perfect, but that seems like a reasonable policy to me.
Sounds like a perfectly reasonable approach.Typical of Canada’s health care system.
Back when I was administrator of our office’s small group plan with Oxford/United Health, I remember getting a notice that reimbursement was changing from being based on UCR to 140% of Medicare reimbursement rate. They explained it using the example of OOP costs for a colonoscopy. Long story short, the OOP cost to patient was several times as high.
My last colonoscopy was in 2014. After the procedure, I asked the gastro if, since screening colonoscopies were supposed to be covered under the ACA, the procedure would cost me. Actually got into an argument with me whether it was a screening colonoscopy or not. (On top of that, I later got an EOB explaining that since the anesthesiologist was not in network, I was not covered for the anesthesia. I know NY has a law in place similar to the No Surprises Act–probably why I never got that bill for over $3K).
Planning on another colonoscopy later this year–first time on Medicare.
If you qualify, Medicare pays 100% for Cologuard, a safe and effective stool DNA test for colon cancer without the invasive risks of a colonscopy. My primary care physician recommended it every three years. Even without insurance, it costs about $700.
I’m a fan of Cologuard and have a negative test 2 years ago
I seems to me that while screening and diagnostic have different meanings the colonoscopies are the same procedure. So why is one free (or low cost) and the other not free? This is the irrationality of medical pricing and insurance .
I would steer clear of the virtual colonoscopies. You still have to drink that prep fluid for them* and the amount of radiation involved likely increases your chances of getting cancer. Disclosing this radiation was a kerfuffle at the FDA years ago. https://www.nytimes.com/2010/03/29/health/policy/29fda.html
There is also now a blood test that can be done. https://bit.ly/3xj6dOo
*And one must recall the immortal words of the great philosopher Dave Barry on the subject: “I don’t know what’s in that stuff, but it should never be allowed to fall into the hands of America’s enemies.”
Thank you for mentioning the blood test–I’ll ask my doctor about that one.
I’ll be writing more about the alternatives to colonoscopy. I’m actively investigating the virtual CT colonoscopy for myself. Determining cost, expertise, adverse effects and availability of this procedure may be as difficult as for the real colonoscopy
Very valuable information to know before hand. I was looking within the article for the definition of KHN and KFF. It wasn’t until I scrolled to the page bottom did I find the meaning. Including it at the point of introduction of the abbreviation would be helpful and following approved styles of writing.
IMHO the medical billing system is broken. In all other retail systems there is a price or fee based on competition and the cost of doing business. For medical it appears that these parameters are out the window. Years ago I had a prostatectomy that the surgeon billed for $38K but took 3.8K as payment in full from the in network third party. Where is the real price point in all of this?
The system is badly broken, I agree. Competition on price cannot exist without some transparency and some connection to quality or outcomes.