A preventative colonoscopy -- or no?

[milovany]

So I'm almost 52 and put off having a colonoscopy for a couple of years, until last December. I had just started seeing a new PCP (a naturopath) in November and she wanted both a mammogram (also something I'd never had) and colonoscopy for baseline information.  I wasn't having any issues whatsoever but I finally gave in and had the procedures.These were both preventative/screening tests covered by insurance.  

 

The results of the mammogram were great (no issues).  I had the colonoscopy after that, and had one small polyp that they removed during the procedure. 

 

When I got the insurance billing back, it showed that they had processed the colonoscopy as diagnostic, instead of preventative, because of the polyp that they removed.  Apparently the type of procedure changed while I was under, on the table.  That meant I owed several hundred dollars because we hadn't met our deductible yet. 

 

Does this make sense to you?  I thought the point of a preventative procedure was to screen for any issues to catch them before they got to be huge problems.  I get that I owe for the removal of the polyps -- that I'm fine with. That billing came from the doctor's office. But the colonoscopy billing came from the hospital where the procedure occurred, and I just don't understand it becoming a diagnostic procedure instead of a preventative one just because they found something.  Is it only preventative if they don't find something?  That doesn't seem plausible to me. 

 

I have a dispute registered with the hospital and they are looking into it but I thought I'd get some feedback here to see if I'm just way off in thinking that the colonoscopy (not the polyp removal) should have been processed as a preventative procedure, at no cost to me.  Thoughts? 

 

ETA - By the way, it's not the insurance company who created the situation.  They said they just processed the codes given to them by the hospital and doctor's office.  It's was the doctor's office that changed the coding from preventative to diagnostic, and that's what the hospital is checking into. 

Edited March 16, 2018 by milovany

[Seasider]

Well the removal likely includes a biopsy and is, in fact, a different procedure.

 

I've had numerous colonoscopies and every time my physician makes it clear that if anything like a polyp is discovered, it will be removed and biopsied. It was clearly understood that the cost might change. But why would I want to leave a polyp in there, y'know?

[Kassia]

I think this is common and it's absolutely ridiculous that patients don't know until after the procedure if they will be covered by insurance (for screening) or not (diagnostic).  Even if hemorrhoids are found, it can be billed as diagnostic.  Makes me so mad.  

 

ETA:  I found this on the internet a while back about the billing:  "It is still screening as long as the patient was asymptomatic at the time with no expectation of any abnormality." 

 

Anything found should be an incidental finding and listed as a secondary diagnosis.  

Edited March 16, 2018 by Kassia

[milovany]

Well the removal likely includes a biopsy and is, in fact, a different procedure.

 

I've had numerous colonoscopies and every time my physician makes it clear that if anything like a polyp is discovered, it will be removed and biopsied. It was clearly understood that the cost might change. But why would I want to leave a polyp in there, y'know?

 

 

Like I said, that I get.  I will pay for anything related to the polyp, its removal, and the testing.  What I'm disputing is the charge for the colonoscopy, not the removal or the biopsy. 

 

[milovany]

I think this is common and it's absolutely ridiculous that patients don't know until after the procedure if they will be covered by insurance (for screening) or not (diagnostic).  Even if hemorrhoids are found, it can be billed as diagnostic.  Makes me so mad.  

 

Exactly.  Honestly, I probably wouldn't have had the procedure done if insurance wasn't going to cover it. But insurance does cover a preventative colonoscopy now so that people will get them done.  If they're not going to be covered by insurance, fewer people will get them done, effecting a result that they say they're trying to avoid (costly procedures later if the polyp develops into cancer, or some such thing).

[milovany]

you should talk to your insurance people...they are good at getting the hospital to bill correctly

 

I have talked to them.  They say it's up to the doctor and hospital.  If the hospital comes back with an unfavorable decision, I may contact them again. 

[Kassia]

Exactly.  Honestly, I probably wouldn't have had the procedure done if insurance wasn't going to cover it. But insurance does cover a preventative colonoscopy now so that people will get them done.  If they're not going to be covered by insurance, fewer people will get them done, effecting a result that they say they're trying to avoid (costly procedures later if the polyp develops into cancer, or some such thing).

 

 

Right.  It's really not fair to have the cost change while you are knocked out!  I had a problem last week when my prep didn't work and I was scheduled for colonoscopy/endoscopy.  I told everyone at the hospital that I didn't want the endoscopy without the colonoscopy since I could just have it later since I'd have to try the colonoscopy again.  They went ahead with the colonoscopy, which they had to stop right away, and then did the endoscopy.  So now I am going to have a huge bill and I am very upset about it.  

 

 

 

I have talked to them.  They say it's up to the doctor and hospital.  If the hospital comes back with an unfavorable decision, I may contact them again. 

 

My doctor's office billed mine as diagnostic and I spoke with the doctor directly, who said it should have been billed as an aborted screening so I could have it again.  Maybe your doctor and he can help?  

[Sharpie]

When we had traditional insurance, this is exactly what we were warned about.  My dh called our insurance and was told it's covered as preventative but if anything is found, it no longer is preventative but diagnostic and he'd be charged. 

[EKS]

This is literally the dumbest thing I've heard in a while.

 

Isn't having a polyp removed preventative--as in, isn't it *preventing* cancer from developing?

 

If they want to encourage people to have colonoscopies, this isn't the way to do it.

[PrincessMommy]

This sounds akin to bait and switch.  What is the percentage of finding a polyp in people over 50?

Edited March 17, 2018 by PrincessMommy

[Ali in OR]

I agree that it's completely unfair, but I think it's a regular thing. I've heard of similar locally with mammograms--it's preventive unless they find something.

[milovany]

This sounds akin to bait and switch.  What is the percentage of finding a polyp in people over 50?

 

I've read a variety of estimates and 50% or more wouldn't be out of the range of possibility for a minimum.  I like the bait and switch analogy.  It just seems so weird to me. 

 

Prevent: = if you find something, you can prevent something more serious from developing (if you don't find anything, what are you preventing? Nothing, you're just kind of sighing a sigh of relief).

 

Diagnostic = determining what it is if something is already wrong with you. That's what diagnosis means.  Someone I know had blood in his stool, therefore his colonoscopy was diagnostic.  They had to diagnose the problem. 

Edited March 17, 2018 by milovany

[SparklyUnicorn]

I don't know.  Doesn't really surprise me though.  I had an upper GI scope and they treated that as surgery even though they only looked and took biopsies.  I guess biopsies are cutting, but I thought the point was diagnostic.  It was shockingly expensive.

 

 

[SparklyUnicorn]

I guess what they did was better than leaving the polyp and then telling you you have to come back to have it removed and then recharging all over again for a surgery.  So there is that...

 

Sorry!  I thought I had upper GI pain, but the real pain came when I got the bill.  :glare:

[J-rap]

Wow, that seems really dumb and frustrating!  I would keep fighting it.  I'd maybe contact your congressman/woman and tell them about it, after you gather some more information such as what Patty said above regarding ACA (Obamacare) mandating coverage of first colonoscopies, the percentage of people who do have a polyp removed during their first "preventative" colonoscopy, etc.

 

Good luck!

[Laurie4b]

I'm confused. Would you have wanted a second procedure if they had found a polyp and left it in there? 

[milovany]

I'm confused. Would you have wanted a second procedure if they had found a polyp and left it in there? 

 

I don't mind at all that they removed the polyp.  I knew going into it that they would if they found anything, and that this removal and biopsy would be billed under our deductible (although I'm questioning that a little bit, too, since that's also "preventative" -- preventing cancer by removing the polyp).  But what I'm disputing is the screening procedure itself (the colonoscopy). A first time screening colonoscopy when one is asymptomatic is a preventative procedure and per the ACA should be covered, from what I understand.  If I look at the entire bill for the procedures (colonoscopy + removal + biopsy), the colonoscopy makes for about 65%-70% of the total costs if I am recalling the math correctly.  I received two separate billing notices (one for the colonoscopy and one for the removal/biopsy).  It's the colonoscopy costs that should be covered. Nothing changed the fact that the reason for having the colonoscopy in the first place was screening/preventative. 

Edited March 17, 2018 by milovany

[poppy]

I get that you're frustrated , but I think it's an issue of your doc office not communicating, not the insurance company screwing up.  I can't wrap my head around the idea that a biopsy is not diagnostic. 
If it was single payer, it wouldn't matter.

[kitten18]

I get that you're frustrated , but I think it's an issue of your doc office not communicating, not the insurance company screwing up. I can't wrap my head around the idea that a biopsy is not diagnostic.

If it was single payer, it wouldn't matter.

But if I’m understanding. It’s not about the biopsy, she has said she understands why she’s paying that.

 

It’s about just the colonoscopy procedure. The purpose of the procedure was preventative. She didn’t go in with symptoms and they did the procedure in order to diagnose something.

[Catwoman]

But if I’m understanding. It’s not about the biopsy, she has said she understands why she’s paying that.

 

It’s about just the colonoscopy procedure. The purpose of the procedure was preventative. She didn’t go in with symptoms and they did the procedure in order to diagnose something.

Yes, exactly! She didn’t go for the colonoscopy because she knew (or even suspected) she had a problem. She went simply because it’s a recommended preventative procedure. She had no idea before the procedure that the doctor would find anything at all.

[Catwoman]

I just today opened a bill from the lab where they sent the 1 polyp they removed; they wanted to test for cancerous/benign. (Benign.). The lab work was not covered under our insurance or the ACA laws (we do not have ACA insurance), and it was about $100.

 

Just more info for you.

Yay for benign!!! :hurray:

[milovany]

I get that you're frustrated , but I think it's an issue of your doc office not communicating, not the insurance company screwing up.  I can't wrap my head around the idea that a biopsy is not diagnostic. 

If it was single payer, it wouldn't matter.

 

Everything you said here is kinda the opposite of what I've said above.  In the OP, I said outright that it was not an issue with the insurance company, but with the doctor and hospital's coding of the procedure.  Several times in the OP and responses I've I said I don't  dispute paying for the removal and biopsy; that I knew going in that if anything was found, we would pay for those things. It's the procedure -- the colonoscopy -- that I don't understand paying for when it was preventative/screening, since I was asymptomatic. We're told over and over that we should get a colonoscopy at around 50, and that (to make that easier/more frequent) they will be coded as preventative because of the good that they do and so that more people get them as a result.  So I don't understand being charged for that.

 

The dispute has been on the hospital's desk for a month and a half or more now, which hopefully is good news.  They try to answer all such disputes within a month and I got a letter after the first 30 days saying they were still looking into it.  I really feel like it's something I will press if they come back saying that a colonoscopy that was originally preventative will be billed as diagnostic if anything is found.  The point of the preventative is TO find something (if something is there) so it can be taken care of at an early, pre-cancerous stage rather than later as Stage III or Stage IV cancer. 

[Catwoman]

I think you’re doing the right thing by continuing to fight this.

[Bambam]

I've had this happen every time I've had a preventative thing - mammo - they find something "suspicious" so I have to go back for an ultrasound. Now that mammo - which was preventative - no longer is.  Same with colonoscopies - they find and remove any polyps - again it isn't preventative, so I end up paying. I hate it. If you win, please post. 

[umsami]

Some articles which might help on the prevalence of polyps in screening colonoscopies:

 

This suggests 25% of women will have polyps, but national guidelines suggest only 15% would.

 

https://www.sciencedaily.com/releases/2013/02/130218132359.htm

 

This also says 15-25%

http://www.berkeleywellness.com/self-care/preventive-care/article/truth-about-colon-polyps

 

 

This also may apply to insurance:

https://www.kevinmd.com/blog/2013/10/obamacare-covers-screening-colonoscopies-catch.html

 

"A check at healthfinder.gov stated that colonoscopy was covered by the ACA and that, “if your doctor finds polyps inside your colon during testing, these growths can be removed before they become cancer.â€

 

I decided to call the doctor’s billing office to check. After the clerk talked to her supervisor she called back to say that I was correct that there was to be no deductible if it was a simple “screening†colonoscopy. But since the doctor had found and removed a polyp it became a therapeutic procedure. Medicare and Medigap (and apparently commercial insurers as well for those under 65) do not recognize this as a preventive screening procedure under the ACA guidelines. Hence I was on the hook for the remaining $65.52"