Medicare: Colonoscopy Cost

Preventives screenings are covered by Medicare and they are covered by all health insurance plans as a result of Obamacare.  This means a person should have no co-pay and no deductible cost when getting a preventive screening test.  So what should you do if you get a bill?

Last week I wrote about how a colonoscopy turns into a billable procedure. But then a friend of mine told me she got a bill for her colonoscopy even though no polyps were found. So why did her insurance require her to pay $336 for this preventive screening test?

We checked her insurance plan details and she has a $300 deductible on her employer policy. This is very good health insurance because it has such a low deductible. Then I looked closely at the bill she received from the surgery center – and I saw the procedure was called “diagnostic” rather than “routine” or “preventive“.  Ah ha!  There was the reason for the bill!

Because the test was labeled “diagnostic” my friend would have some co-pay. And because her insurance has a deductible, she would have to pay an amount up to her deductible.

The bill says the colonoscopy cost $1,300.  Of course the insurance company doesn’t pay this price because they have a contracted price of $540, according to the bill.  So UnitedHealthcare paid $204, and the patient got a bill for $336. After the deductible she has a 15% co-insurance, which amounted to $36. Still a good deal – except that she should not have had any bill for what she thought was a preventive screening colonoscopy.

After several calls to the insurance company and the doctor’s office, we learned something new.  It turns out that my friend had her first colonoscopy five years earlier and polyps were found, removed, and a biopsy was performed on them.  The biopsy showed no cancer, but she was told to get her next screening in five years rather than the standard ten years.   So, a colonscopy every ten years gets labeled “preventive screening” while one done at five years is labeled “diagnostic”.   The billing was correct and my friend had to pay the $336 bill.

LESSONS LEARNED:

1)  Everyone needs to understand how their health insurance plan works: what your plan’s deductible is; what the co-insurance is; what co-pays are.

2) Understand what preventive screenings are and how they can end up as something more.

3) If you get a bill, read it thoroughly so you can tell if there is a reason for the bill – and that the reason (as in the billing code) is correct.

4) Call the Member Services number on the back of your health insurance card and ask your insurance company to explain the bill and help you figure out how to fix a mistake – or if there was not a mistake and the bill is correct.

What Next?

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