Colonoscopy Not Covered. Should we challenge this?

[Pink Partridge]

Husband is 48 years old. He saw a new physician for a physical and the doctor said he should get a colonoscopy due to his father’s death due to colon cancer. Colonoscopy is scheduled. Office doing procedure says it will be $40. That is it. Procedure was a breeze. No polyps found. Come back in 5 years.


We received a bill from the office. It is our deductible and then 15% on top of that. Called insurance company. Lady on phone says “Must be a mistake. Let’s put it in for review”.

Letter comes yesterday saying “Non-routine Colorectal Cancer screening is processed at 85/15 subject to deductible”.

Non-Routine?


Grrr. He would have waited until January to have this done had they been more clear on this. Why was this non-routine if doctor suggested it for preventative screening? He is not 50. But even office doing it said it would be $40, and they had access to his age.


So, insurance experts, does his father’s death from colon cancer make this a preventative scope?


Is it even worth it to challenge this decision?

 

[Owlpost23]

I would.Involve the office that knew his age and had him do it anyway-because of his father's death from colon cancer.

 

[design_mom]

Mine aren't covered either. It's the difference between whether it's considered preventative (covered 100%) or diagnostic (not covered 100%). I have a diagnosis that makes regular colonoscopies recommended (fun, fun). They cost us a fortune each time.

I think the 'recommendations' are that people between 50 and 75 get screened preventatively. Since he's outside the suggested age range, I think there's a good chance it was considered diagnostic. If he wasn't having ANY symptoms at all, then MAYBE you can argue that it was preventative. HOwever, sadly, my guess is that they're giong to say that it isn't... and that it was your responsibility to check with the insurance company before having the procedure (so even though the office told you it would just be $40, they were wrong and you're still responsible.)

 

[lahobbs4]

My husband had his first this year at 36 for the same reason. The nurse basically said we HAVE to say it was because of 'black stool' (even though he hasn't had any) because insurance wouldn't pick it up unless we did.

 

[Pink Partridge]

My husband had his first this year at 36 for the same reason. The nurse basically said we HAVE to say it was because of 'black stool' (even though he hasn't had any) because insurance wouldn't pick it up unless we did.

But I think the way to have it covered 100% is it to NOT be diagnostic. Which it wasn't for my husband. He had absolutely no symptoms. His doctor just wanted him to have a preventative screening due to family history.

 

[DisneyHardin]

My DH had one when he was 38 because the dr had some concerns. Since we hadn't met our deductible yet, we were responsible for a pretty large bill for it.

I think even if the doctor orders it, you will be responsible for the bill if you haven't met your deductible unless there is some sort of clause in your insurance about colonoscopys.

 

[Boardwalk Jedi]

We paid about $400 for DH's. Most offices let you set up a plan if you're not covered. If it turns out you have to pay a lot, try and think of it as money well spent. Colon cancer is beatable if caught early and since your DH has a family history of it, it's best to test early.

 

[Southernmiss]

We paid about $400 for DH's. Most offices let you set up a plan if you're not covered. If it turns out you have to pay a lot, try and think of it as money well spent. Colon cancer is beatable if caught early and since your DH has a history of it, it's best to test early.

This. DH needed one a few years ago in his mid 40s as he was having some concerns. Turned out to be nothing. The peace of mind is so worth it. Today, about 3 years later, I can't even tell you what we paid out of pocket. It doesn't really matter in the grand scheme of things.

Have a friend whose father died young from colon cancer.

I'll add, I had a routine mammogram in December last year. Showed some concerns. I went and had a more conclusive mammogram the next week. Also turned out to be nothing. But for the 5 days until the 2nd mammogram, I was so concerned and went through all the worse case scenarios in my head.

Peace of mind that all was okay for Christmas was also worth it. Even if it was just 2 weeks before the new year.

DS now 21 had a medical scare in February this year. For that week, we lived in hell. After having been told first 2 tests looked like cancer. Again, we were fortunate that it was not cancer and manageable, but still something to treat and watch.

 

[sam_gordon]

I think the 'recommendations' are that people between 50 and 75 get screened preventatively.

The recommendation changed earlier this year that the first screening should be done at age 45 (as I found out at physical on Friday). https://www.cancer.org/latest-news/...es-colorectal-cancer-screening-guideline.html

I'm guessing the procedure got coded wrong. Check with the office that did the screening. Can/will they resubmit to insurance so it's coded as "preventative"? Since my doc says I need to get one (I'm 48), I started checking with insurance and yes, they cover preventative at 100%, but diagnostic at less than 100%. It's to your benefit to have it coded as preventative.

 

[kdonnel]

My husband had his first this year at 36 for the same reason. The nurse basically said we HAVE to say it was because of 'black stool' (even though he hasn't had any) because insurance wouldn't pick it up unless we did.

So they admit to insurance fraud and involve you in insurance fraud?

Not sure I would return to that facility.

 

[jerseygal]

Did the insurance company consider this diagnostic rather than preventative? It is my understanding that the Affordable Care Act, ACA mandated that colonoscopy was 100 percent covered, but If the colonoscopy is performed due to an issue, it might be considered diagnosiic. I remember when I had my colonoscopy, mine was not covered at 100 percent, I called they asked me if there were issues and if it was diagnostic. I explained that there were no issues, only preventative, and they corrected the billing. Doesn’t hurt to call and research!

 

[kdonnel]

Mine aren't covered either. It's the difference between whether it's considered preventative (covered 100%) or diagnostic (not covered 100%).

My wife ran into a similar issue with a colonoscopy.

An ER visit that resulted in a followup with a doctor who ordered a colonoscopy. They were very upfront that this was going to be diagnostic and would not be covered as such. We would need to meet our deductible and co insurance requirements.

Something similar applies to tests run while in the ER. For our $75 ER copay they performed many tests that would have cost us $1,000's if ordered by her physician. But since they were ordered by the ER doctor they were 100% included in the ER copay.

In the end she had $15,000 worth of services for the $75 copay at the ER and then we paid $800 for a $1,500 colonoscopy.

 

[Pink Partridge]

Today, about 3 years later, I can't even tell you what we paid out of pocket. It doesn't really matter in the grand scheme of things.

While we are both very relieved and thankful, we also don’t equate that with being ok that our insurance company may be taking advantage of us. To us, the money DOES matter if we are not responsible for paying it.


I was under the impression that preventive screenings were covered under the ACA.

 

[mom2rtk]

While we are both very relieved and thankful, we also don’t equate that with being ok that our insurance company may be taking advantage of us. To us, the money DOES matter if we are not responsible for paying it.


I was under the impression that preventive screenings were covered under the ACA.

It's only preventive if it's coded that way. As noted by a PP, you need to call and see how it was coded.

 

[Southernmiss]

While we are both very relieved and thankful, we also don’t equate that with being ok that our insurance company may be taking advantage of us. To us, the money DOES matter if we are not responsible for paying it.


I was under the impression that preventive screenings were covered under the ACA.

I get that $$ matters. Believe me, I get it. But looking back on our situation, and seeing what really could have been...3 years later it truly doesn't matter because all is okay.

Cancer care is even more expensive than a routine non positive test. For good health, I am immensely thankful. To me that is priceless.

There are many problems with American health care today. It is what it is. I've thought the cost issues to us would have been far behind us as an American people. But we are not. So we deal with what we have.

I would say, yes ask questions of your insurer, but if it works out that you are responsible, pay it and go on. The whole situation will be a fading memory before too long.

 

[FlightlessDuck]

https://www.cancer.org/cancer/colon...on-diagnosis-staging/acs-recommendations.html

The ACS recommends that people at average risk* of colorectal cancer start regular screening at age 45.

And your husband has a higher than average risk to due to family history of colorectal cancer.

As someone else said, check to see how your doctor coded the exam.

 

[Pink Partridge]

Just got off the phone with scope office to ask about the coding (thank you for suggestion). They had documented that insurance company was called before procedure and told them (the office) that the procedure would be paid for 100%. They have the reference number and even the first name of the woman that told them "covered 100%".

She said that her best guess is insurance saw husband was not 50 when bill came and just automatically said we had to pay deductible.

And even though insurance "reviewed it", they still are trying to collect on their misinformation.

We will be challenging for sure.

 

[sam_gordon]

Just got off the phone with scope office to ask about the coding (thank you for suggestion). They had documented that insurance company was called before procedure and told them (the office) that the procedure would be paid for 100%. They have the reference number and even the first name of the woman that told them "covered 100%".

She said that her best guess is insurance saw husband was not 50 when bill came and just automatically said we had to pay deductible.

And even though insurance "reviewed it", they still are trying to collect on their misinformation.

We will be challenging for sure.

But did the office actually code the procedure as preventative? I have a hard time believing billing would be handled by a phone call. I'm not in the medical field and I didn't stay at a Holiday Inn last night, but I'm assuming even if the doctor's office called to get approval, if the office files it as a "diagnostic" procedure, it will be treated as such (and then not covered at 100%). If they file as "preventative", then it is covered. Did the office tell you they coded it as preventative? If not, ask them to refile. If so, then call the insurance (or get a copy of the EOB) and complain.

 

[Gumbo4x4]

But I think the way to have it covered 100% is it to NOT be diagnostic. Which it wasn't for my husband. He had absolutely no symptoms. His doctor just wanted him to have a preventative screening due to family history.

I have a similar family history & have had several preventative colonoscopies pre-50. Of course, should they find ANYTHING, they can change the billing to “diagnostic” on the spot & ding me for the entire cost.

I feel it’s a bit like taking your car in for warranty work on the transmission. If they happen to notice the wiper fluid is low while it’s there, they’re no longer required to cover the transmission under warranty. Outside of the medical industry, such practices would be illegal.

 

[tvguy]

The recommendation changed earlier this year that the first screening should be done at age 45 (as I found out at physical on Friday). https://www.cancer.org/latest-news/...es-colorectal-cancer-screening-guideline.html

I'm guessing the procedure got coded wrong. Check with the office that did the screening. Can/will they resubmit to insurance so it's coded as "preventative"? Since my doc says I need to get one (I'm 48), I started checking with insurance and yes, they cover preventative at 100%, but diagnostic at less than 100%. It's to your benefit to have it coded as preventative.

I think you may have zeroed in on the issue. The accepted practice is age 50, but now the recommendation is to start doing them at 45. Not sure the health care industry and insurance industry has adopted 45 yet.

OP, how old was your husband's father when he was diagnosed?

My (now former) Doctor was of the mindset that it wasn't necessary until 55. He did do the stool samples every year after age 50, which the Cancer Society seems to feel is adequate. And when I finally did have it done, all was clean.
https://www.cancer.org/cancer/colon...n-diagnosis-staging/screening-tests-used.html