Being billed for a colonoscopy

[deanbrew]

The misses had a colonoscopy a couple of months ago. She's had two before, and I've had three before, and we never got billed for anything. These were in a different state with different doctors and a different insurance company, but I don't think that should matter under ACA laws.

She got a bill for about $1,500 a couple of weeks ago. I went on our insurance website to look at the EOB, and it wasn't available yet. Ok, I thought that perhaps the claim is still in process, and the insurance company will figure it out and eliminate the charges. Nope, we received the EOB in the mail yesterday, and it shows that we owe $1,514, from charges that total $3,550.

I've done a little research, and discovered that screening colonoscopies are fully covered under the ACA, but diagnostic ones are often not.

Should I start my battle by filing an appeal with the insurance company, or should I contact the providers (four separate ones are listed on two bills)? Should I also contact the state insurance commission?

Any advice is appreciated.

 

[Yagents]

The misses had a colonoscopy a couple of months ago. She's had two before, and I've had three before, and we never got billed for anything. These were in a different state with different doctors and a different insurance company, but I don't think that should matter under ACA laws.

She got a bill for about $1,500 a couple of weeks ago. I went on our insurance website to look at the EOB, and it wasn't available yet. Ok, I thought that perhaps the claim is still in process, and the insurance company will figure it out and eliminate the charges. Nope, we received the EOB in the mail yesterday, and it shows that we owe $1,514, from charges that total $3,550.

I've done a little research, and discovered that screening colonoscopies are fully covered under the ACA, but diagnostic ones are often not.

Should I start my battle by filing an appeal with the insurance company, or should I contact the providers (four separate ones are listed on two bills)? Should I also contact the state insurance commission?

Any advice is appreciated.

If you have a history of polyps in past colonoscopies, then it is considered diagnostic going forward and subject to your deductible.

If preventative care, with no history of polyps, then it should be free.

Its all in the claim coding. Verify with carrier first on what coding was submitted, then if wrong, call provider to resend claims with correct coding to preventative care.

Assuming all was in network. If this was first ever polyp found during screening, they are not allowed to change coding after the procedure. If went in under prev care, then you come out under preventative care coding, by law.

 

[somarco]

If you have a history of polyps in past colonoscopies, then it is considered diagnostic going forward and subject to your deductible.

I am under the impression it is preventive UNLESS a polyp is removed for biopsy. Some polyps, especially a flat one, are too small to be removed.

And as @Yagents stated, your appeal would be with the provider, not the carrier.

 

[Yagents]

Once you have a polyp, the next colonoscopy is considered diagnostic given the now existing history. Plus, if polyp over 10mm or more, then next test is 3 yrs from now vs five years. Know that from recent personal experience.

Like a pap smear, first one is prev care and free, but if positive, second follow up is diagnostic

 

[Yagents]

Cancer screenings like colonoscopies are supposed to be free. Hers cost $2,185

 

[Yagents]

Insurance Coverage for Colorectal Cancer Screening

 

[deanbrew]

Thank you. We called BCBS, and we're told that because the doc found a polyp, as well as evidence of a susceptibility for diverticulosis, the procedure changed from screening to diagnostic.

So then we called the provider, who said they added a procedure suffix code of "33", which indicates that the procedure changed from screening to diagnostic, but should be handled by the insurance company as a screening procedure. She said they've run into this issue before with insurance companies.

They said they would resubmit the claim with an explanation, and hopefully we wouldn't owe anything. I'll wait until I get new bills and EOBs.

 

[ehall2]

Yep, companies consider it diagnostic if a polyp is found in a previous colonscopy. Doesn't seem right but I went through this with Aetna.

 

[deanbrew]

Yep, companies consider it diagnostic if a polyp is found in a previous colonscopy. Doesn't seem right but I went through this with Aetna.

Not doubting your experience, but I've had three colonoscopies. Polyps were removed all three times, and I never paid a dime. Seems like inconsistent coding, reimbursement and billing between providers and insurance companies.

 

[ehall2]

I know what you are saying but I only know what Aetna does.