Colonoscopy: A Necessary Evil For Life Insurance Applicants?

Colonoscopies are a critical procedure for detecting colorectal cancer, which is the second leading cause of cancer death in the US. The average cost of a colonoscopy in the US is $2,125, with nearly $80 in out-of-pocket fees. The Affordable Care Act (ACA) mandates that private insurers and Medicare cover the costs of colorectal cancer screening tests, but there are still some costs that patients may have to cover themselves. For example, Medicare covers screening colonoscopies once every 24 months for those at high risk of colorectal cancer, and once every 120 months for those not at high risk. If a polyp is removed during the procedure, patients may be charged 15% of the Medicare-approved amount for their doctor's services. This has caused confusion, as the US Department of Health and Human Services has stated that removing polyps is an integral part of a screening colonoscopy and should not incur shared costs. This article will explore the costs of a colonoscopy with and without insurance and how to minimise out-of-pocket expenses.

Colonoscopy costs with and without insurance

The cost of a colonoscopy in the US varies depending on several factors, including insurance coverage, the type of procedure, and the facility where it is performed.

Colonoscopy Costs with Insurance

If you have private health insurance or Medicare, a screening colonoscopy is typically covered with no out-of-pocket costs as a preventive health service under the Affordable Care Act (ACA). This means that insurers should not charge copays or deductibles for these screening tests. However, it's important to review your insurance plan's specifics, as some plans may have different requirements or limitations.

It's worth noting that a diagnostic colonoscopy, which includes a biopsy or excision, is not considered preventive and can trigger your deductible, copays, and coinsurance. If a polyp or other tissue is found and removed during a screening colonoscopy, it may be classified as a diagnostic procedure, resulting in out-of-pocket expenses.

The cost of a colonoscopy with insurance can also vary depending on whether the providers involved, such as the anesthesiologist, are in-network or out-of-network. It is advisable to confirm that all providers are in-network before the procedure to avoid unexpected charges.

Colonoscopy Costs without Insurance

Without insurance, the cost of a colonoscopy in the US can range from \$1,250 to \$4,800 or more, with an average cost of around \$2,750. The price varies depending on the setting, with outpatient facilities costing around \$2,550 and inpatient facilities costing approximately \$4,350.

It is important to note that individuals without insurance may be responsible for the full cost of the procedure and related services, such as anesthesia and pathology lab fees.

Minimizing Colonoscopy Costs

There are options to minimize the cost of a colonoscopy, whether you have insurance or not.

• For insured individuals: It is recommended to confirm coverage and understand potential out-of-pocket costs beforehand. Asking questions and advocating for yourself is essential. Ensure that all providers involved in the procedure are in-network to avoid unexpected charges.
• For uninsured individuals: There are programs and organizations that offer free or low-cost colonoscopies, such as the Colorectal Cancer Alliance and ColonoscopyAssist. Additionally, comparing costs between different facilities and choosing an outpatient center over a hospital can result in significant savings.

The cost of a colonoscopy can vary significantly depending on insurance coverage, the type of procedure, and the facility where it is performed. It is important to understand your insurance coverage and potential out-of-pocket expenses before undergoing the procedure to avoid unexpected financial burdens. For those without insurance, there are resources available to access affordable or free colonoscopies, emphasizing the importance of regular colorectal cancer screenings.

Colonoscopy screening coverage under Medicare

Colonoscopies are covered by Medicare as a preventive measure for colorectal cancer. The US Preventive Services Task Force (USPSTF) recommends that people at average risk should start colorectal cancer screening at age 45. Medicare covers screening colonoscopies differently depending on the patient's risk level. If a patient is at high risk for colorectal cancer, Medicare covers a screening colonoscopy once every 24 months. For those not at high risk, Medicare covers the test once every 10 years, or 48 months after a previous flexible sigmoidoscopy. There is no minimum age requirement for this procedure under Medicare.

If a patient initially has a non-invasive stool-based screening test (such as a fecal occult blood test or multi-target stool DNA test) and receives a positive result, Medicare also covers a follow-up colonoscopy as a screening test.

In terms of costs, if the doctor or healthcare provider accepts assignment, the patient pays nothing for the screening test(s). However, if the doctor finds and removes a polyp or other tissue during the colonoscopy, the patient pays 15% of the Medicare-Approved Amount for the doctor's services. In a hospital outpatient setting or ambulatory surgical centre, the patient also pays the facility a 15% coinsurance amount. The Part B deductible does not apply.

The specific amount a patient owes may depend on several factors, including other insurance coverage, the doctor's charges, the type of facility, and the frequency of services. It is important to ask questions and understand why a doctor is recommending certain services and how much Medicare will cover.

Medicare also covers other types of screenings for colorectal cancer, with time frames based on age and risk factors. These include:

• Fecal occult blood test (FOBT) or fecal immunochemical test (FIT) once every 12 months.
• Stool DNA test (Cologuard) every 3 years for people ages 45 to 85 who are not at increased risk of colorectal cancer and do not have symptoms.
• Flexible sigmoidoscopy every 4 years, but not within 10 years of a previous colonoscopy. Covered once every 2 years for those at high risk and once every 10 years for those at average risk.
• Double-contrast barium enema if a doctor determines its screening value is equal to or better than flexible sigmoidoscopy or colonoscopy. Covered once every 2 years for those at high risk and once every 4 years for those at average risk.

The Affordable Care Act and its implications for colonoscopies

The Affordable Care Act (ACA) has significant implications for colonoscopies and colorectal cancer screening in the United States. The ACA requires private health insurers and Medicare to cover the costs of colorectal cancer screening tests, as these tests are recommended by the United States Preventive Services Task Force (USPSTF). The law stipulates that there should be no out-of-pocket expenses for patients, such as co-pays or deductibles, for these screening tests. This is important because colorectal cancer is the third most common cancer and cause of death from cancer in both men and women in the US, with high treatment costs.

However, there has been confusion over whether a colonoscopy is characterised as a preventive screening test or a diagnostic test, particularly when polyps are removed during the procedure. This distinction is crucial because, while screening tests are typically covered without patient cost-sharing under the ACA, diagnostic tests may be subject to co-pays and deductibles. Soon after the ACA became law, some insurance companies considered a colonoscopy to be a diagnostic test if a polyp was removed, which would result in additional costs for the patient.

To address this issue, the US Department of Health and Human Services has clarified that polyp removal is an integral part of a screening colonoscopy, and patients with private insurance should not have to pay out-of-pocket for it. This clarification ensures that patients are not discouraged from seeking potentially life-saving screenings due to unexpected costs. However, it is important to note that this clarification does not apply to Medicare, where patients may be responsible for a portion of the costs if a polyp is removed during a screening colonoscopy.

Despite these protections, unexpected costs related to colonoscopies can still occur. For example, patients may receive bills from multiple healthcare providers involved in the procedure, such as the location where the colonoscopy was performed, the anesthesia care team, and the pathology lab. Additionally, the specific amount a patient owes may depend on factors such as their insurance coverage, the fees charged by their doctor, and the type of facility where the procedure is performed.

To minimise unexpected costs, patients are advised to ask their insurance company about potential costs before undergoing a screening colonoscopy. They should also ensure that all healthcare providers involved in the procedure, including anesthesiologists, are in-network with their insurance plan. By being proactive and informed, patients can better manage the financial aspects of this important preventive health measure.

Unexpected colonoscopy costs

Colonoscopies are critical for detecting cancer and improving the chances of a person surviving the disease. However, the procedure can come with unexpected costs. Here are some factors that can result in unexpected colonoscopy charges:

Out-of-Network Providers

It is important to be aware of the coverage for all healthcare providers involved in the colonoscopy. In addition to the gastroenterologist, you may receive bills from the facility where the procedure was performed, the anesthesia care team, and the pathology lab in cases of polyp removal or biopsies. Always inquire about the healthcare providers who will be involved in your procedure and request that they be in-network. If you are not given the option of choosing an in-network provider, you can appeal to your insurance company.

Bowel Prep Kit and Other Services

You may be responsible for paying for your bowel prep kit and other related services. To obtain accurate pricing and avoid unexpected costs, obtain the healthcare provider's current procedural terminology (CPT) code for your colonoscopy. Ask your insurance carrier questions such as whether there are any out-of-pocket costs associated with the CPT code and whether scheduling the procedure at an ambulatory surgery center would be more cost-effective than a hospital outpatient department.

Policy Variations

The insurer might initially approve coverage for a colonoscopy but reverse their decision if screening detects precancerous polyps. Policy details can vary among different insurance providers. It is important to understand your insurance policy and ask questions to avoid unexpected costs.

Procedure Complications

In some cases, unexpected costs can arise due to complications during the procedure. For example, if the healthcare provider punctures your colon during the colonoscopy, you may be responsible for a portion of the resulting hospital stay.

Medicare Beneficiaries

Medicare guidelines differ from private insurance. If a polyp is found during a screening colonoscopy for Medicare beneficiaries, it becomes a diagnostic colonoscopy, and you will be responsible for a copay.

To minimize unexpected colonoscopy costs, it is essential to be proactive, ask questions, and understand your insurance coverage. Obtaining the CPT code and comparing costs using tools like the Procedure Price Lookup Tool can help you make informed decisions and avoid surprises.

Colonoscopy costs without insurance

The cost of a colonoscopy without insurance in the US can range from $1,250 to $4,800 or more, with an average cost of $2,750. The price varies depending on whether the procedure is a screening or diagnostic colonoscopy, and the location of the procedure.

Colonoscopies performed in outpatient facilities have an average cost of $2,550, while those performed in inpatient facilities average $4,350. Ambulatory surgery centers (ASCs) often charge less than half of what hospitals charge for colonoscopy procedures.

If you are uninsured, you can ask for a good faith estimate (GFE) before the procedure and compare prices by calling hospitals and surgery centers. You can also consult the Healthcare Bluebook to compare prices in your area.

There are also programs that offer free or low-cost colonoscopies, such as the New York State Cancer Services Program (CSP), the Colorectal Cancer Alliance, and ColonoscopyAssist. These programs can help reduce the cost of a colonoscopy to just over $1,000.

It is important to note that the cost of a colonoscopy is minimal compared to the cost of ongoing treatment for colon cancer. Experts recommend that most people start colorectal cancer screening at age 45, and those with a high risk of developing the disease may need to begin screening earlier.

Frequently asked questions