Colonoscopy – 5 Money-Saving Tips That May Save Your Life

Written by Joanna Morrow

Joanna Morrow, Principal and Founder of Employer Benefits & Advice, is an employer consultant and advocate who has worked in the employee benefits industry for over two decades. She works diligently to help employers overcome obstacles in their business by sharing her expertise in Human Resources, Benefits & Compensation, Process Mapping, Risk Management and ERISA/DOL/IRS compliance. She is a licensed life and health insurance professional in the State of Arizona and is an active member of the National Association of Health Underwriters (NAHU).

Colonoscopy – 5 Money-Saving Tips That May Save Your Life

On April 15th my father passed away from Stage IV colon cancer. He was 69 years old. A successful, self-employed businessman for most of his life he was diagnosed the same year he retired. Since that time I have made a commitment toward education around the importance of colorectal cancer screening, specifically removing the barriers for obtaining one, including any associated costs. 

The Bad News . . .

  • Colorectal cancer is the #2 leading cause of cancer deaths among men and women in the U.S. combined.
  • Colorectal cancer accounts for nearly 10% of cancer deaths in the U.S.
  • 1 in 3 adults aged 50-75 are NOT up-to-date with recommended colorectal cancer screening.
  • The median age at diagnosis is 69 years old.
  • 1 in 20 men and women will be diagnosed with colorectal cancer in their lifetime.
  • The estimated direct medical cost of colorectal cancer treatment in 2010 was $14 billion.

 The Good News . . .

  • In March 2014, the American Cancer Society released data showing colon cancer incidence rates have dropped 30% in the U.S. in the last 10 years among adults aged 50 and older due to the widespread uptake of colonoscopy, with the largest decrease occurring in those aged 65 and older.
  • In January of 2013, the American Cancer Society reported a 30% decrease in the number of people dying from colorectal cancer.

Colorectal cancer screening tests (colonoscopies) are covered by most health insurance plans at 100%, beginning at age 50. The problem I see all the time is that people book their “free” colonoscopy and then receive $1,500 – $3,000 worth of complicated medical bills following the procedure. It can be very frustrating in view of the fact the screenings are listed in your health insurance policy as “covered 100%” or “no charge”.

The following 5 tips will make you an expert when it comes to avoiding the billing nightmare often associated with colorectal screening. Knowing these money saving tips ensures you should pay very little, if anything at all. More importantly, the test itself could save your life. 

WHY you have the procedure:

Over 60% of deaths from colorectal cancer could be avoided with screening. Colorectal cancer screening is included as a covered, preventative service in the majority of health insurance plans. One gastroenterologist told me “Colon cancer is the most preventable cancer there is because it starts with a polyp. If we discover a polyp, we remove it.”

WHERE you have the procedure done:

Remember, as a healthcare consumer part of your job is to understand how the game is played. Insurers pay physicians at a higher rate for services performed in the hospital. If your colonoscopy is scheduled to be performed at a hospital call the gastroenterologist and ask if there is a medical reason. If there is not then request it be moved to the physician’s clinic or surgical center, sometimes called an Endoscopy clinic. Most gastroenterologists have a surgical center attached to their clinic or close by from where they perform colonoscopies and they will usually grant your request without much resistance. It is easier to control your costs and ensure all providers are contracted with your insurance carrier if you stay out of the hospital!

WHO is involved in the procedure:

Typically colonoscopies are performed by medical specialists called “Gastroenterologists”. At the time you schedule the colonoscopy you may receive a package of materials from his office that includes a notice of all the different providers that will be involved in the procedure. I am seeing this more and more these days, which is helpful to you. It generally lists the following roles and responsibilities –

  1. Physician Fee – to pay the physician performing the procedure
  2. Facility Fee – to pay the facility (such as clinic or surgical center) where the procedure is being performed
  3. Anesthesiologist Fee – to pay the guy who promises to knock you out for the duration of the procedure
  4. Pathologist Fee – to pay the guy who examines any biopsies or polyp specimens that may be taken during the procedure.

Always call ahead of time and ensure each of the providers listed above is CONTRACTED (the magic word is CONTRACTED) with your insurance company. IF any one of the above is NOT contracted, then the next thing you do is follow this script for negotiating payment with providers ideally BEFORE the procedure is performed:

You: “My insurance company will reimburse providers based on their contracted rate. Will your non-contracted doctors accept that as payment in full?”

Provider: “Yes, that is our practice. We typically don’t bill patients for the balance.”

You: “Great. Can I get your full name?” (record the name of the person you spoke to and the date you spoke to him/her. This will serve you well in case you have problems down the road when it comes time to pay providers.) Even if you’re told everyone is contracted with your health insurance company, have them list it for you, get a full name and the date you spoke and WRITE IT DOWN.

WHAT the procedure reveals:

If polyps are discovered during the procedure and they are removed, the procedure goes from being classified as “preventative” to “diagnostic” and could potentially generate a bill – it will depend on the billing code used by the provider, and your insurance policy. Don’t you just love insurance? Don’t fret. Any questions should be directed to a benefits professional BEFORE you pay the bill. Do not stop asking questions until you understand what you’re paying for. 

WHEN the procedure is performed:

Typically health insurance plans cover colonoscopies at age 50 and every 2, 5, or 10 years after that depending on the risk you present. If you fall into a high-risk category, for example, someone in your immediate family has had colon cancer, your health plan will usually cover a colonoscopy earlier than age 50 provided you have it “pre-authorized”.

My brothers and I were told by my father’s oncologist that we were at higher risk for colon cancer because of my Dad’s diagnosis. At age 44 I had the gastroenterologist submit a request to my insurance company documenting my risk factors and the insurer then confirmed that the procedure would be covered under the preventative services provision of my plan, even though I’m not yet 50. If you too are considered high risk, ask your physician to submit a pre-authorization to your health insurance carrier to have it covered prior to age 50.

Conclusion

Provided you understand the 5 “W”s laid out above, charges for colonoscopy should be minimal, if at all. A stage IV cancer claim can run between $400,000 – $1,000,000. Colorectal cancer screening can help you to avoid that not to mention the pain and heartache of being diagnosed with a terminal illness that could have been prevented.

If you’re an employer, share this with your employees. Today may be the day you save a life and thousands of dollars in claims costs.