Colonoscopy Costs Aren't Always Accepted by Insurance—Here's How to Get Yours Covered

Here's the deal with colonoscopy costs: options, what insurance covers, and how to make the procedure affordable (even if you're still young).

The death of Chadwick Boseman hit many of us—particularly Black families—hard. Our grief stemmed from both the sorrow of losing a Black American icon and the light shined on the increase in cases and mortality rates of colon cancer for people under 45.

Of course, preventative screening for early detection is key. But how can you get that screening without incurring a huge bill? I recently had my first colonoscopy in New York City at age 40, and the cost without insurance would have been $4,650. Under no circumstances would I have been able to afford that out of pocket.

Here's the deal with colonoscopy costs and how to make the procedure affordable (even if you're still young).

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What happens during a colonoscopy

"The purpose of doing a colonoscopy is to be able to see inside the colon and be able to biopsy or take out polyps from inside the colon," Lisa Ganjhu, DO, gastroenterology specialist in New York City, tells Health. Polyps, she says, are like little pimples in the colon. "Some types of polyps can turn into colon cancer; removing polyps reduces the risk of them turning into colon cancer. The colonoscopy is used for colon cancer screening and for other diagnostic indications."

During the colonoscopy procedure, Dr. Ganjhu explains, a gastroenterologist passes a tube into the rectum; this tube is called a colonoscope. It is a flexible tube with a light source, air source, a suction port, and a channel which allows the passage of instruments—such as biopsy forceps, snares, and brushes. The light and air source allow the examiner to see inside the colon, and the suction port allows the examiner to clean or suction out liquid from the colon.

Who really pays, and what is covered

The Affordable Care Act mandates that both private insurers and Medicare cover the costs of colorectal cancer screening tests, because these tests are recommended by the United States Preventive Services Task Force (USPSTF). The law stipulates that patients should be charged no out-of-pocket costs, such as copays or deductibles, for them. But "guaranteed coverage" can be a slippery concept, and surprise bills are not uncommon. Many insurers use the loophole of how they define "screening" tests to avoid paying for the procedure.

Brett C., a management consultant living in Atlanta, tells Health that he had his first colonoscopy at age 36. He started preventative screenings early because both of his parents were diagnosed with colon cancer and died within three months of each other. (The Centers for Disease Control currently advises that people age 45 and over begin regular colon cancer screenings, but those who are at higher risk of developing the disease may need to be tested earlier.) Subsequent screenings for both Brett and his brothers discovered precancerous polyps.

Brett shared that his "biggest surprise bill was when my doctor punctured my colon during my colonoscopy and I spent three days in the hospital. I had to pay for a portion of those, too. Keep in mind that I worked for a Fortune 100 company, and I'd selected the best health insurance options available."

Besides the costs of any complications from a colonoscopy, patients need to also be aware of coverage for all the providers involved in the procedure. In other words, it's not just the gastroenterologist who has to be paid.

"Regrettably, it's not uncommon for anesthesiologists to be out-of-network, and the bill you get for their work can be awfully surprising," Christin Sonneborn, patient navigator at Colorectal Cancer Alliance, tells Health. "Always ask ahead of time about the providers who will participate in your procedure and request that they be in-network. If you aren't given the choice of using an in-network anesthesiologist, this is through no fault of your own and can be appealed with your insurance."

You may be responsible for paying for your bowel prep kit and other services, too. To get accurate pricing and avoid unexpected costs, obtain the current procedural terminology (CPT) code for your colonoscopy from your doctor. Questions that you should ask your health insurance provider prior to your colonoscopy include: Are there are any out-of-pocket costs for the CPT code being used by the doctor? Is the anesthesiologist being used within network? Will you save money by scheduling the procedure at an ambulatory surgery center (ASC) versus a hospital outpatient department (HOPD)?

Another surprising twist: The colonoscopy might be approved for coverage initially, and then coverage is reversed when precancerous polyps are found. According to Centers for Medicare and Medicaid Services (CMS), "polyp removal is an integral part of a colonoscopy. Accordingly, the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure."

If you are a Medicare beneficiary, however, the screening colonoscopy guidelines differ. If your doctor finds a polyp, the screening colonoscopy is coded as a diagnostic colonoscopy, and you will be responsible for a copayment. Medicare patients can access the Procedure Price Lookup Tool to compare payments and copayments for colonoscopies and other medical procedures performed in ASCs and Hospital Outpatient Departments (HOPDs).

Sonneborn explains that "recent Medicare guidelines encourage coding and billing of colonoscopies based on intent, which means that if your colonoscopy was scheduled as a preventive screening, it should remain as such, whether it finds and removes polyps or not. That's only fair, because no one goes into a routine screening expecting bad news. If a patient is being responsible and following through with preventative screening, they shouldn't be penalized with a surprise bill because polyps were found."

Getting your colonoscopy covered by insurance when you're under 45

Having a colonoscopy done and approved by your health insurance provider is largely dependent on your medical history. Dr. Ganjhu explains that "it should be done in younger people if they have certain risk factors, such as family history of colon cancer or polyps under the age of 45. In terms of a diagnostic colonoscopy, it will be performed in patients exhibiting alarming symptoms, such as bleeding, a change in bowel habits, change in stool caliber, diarrhea, constipation, abdominal pain, or weight loss, she adds.

Your medical history will determine whether you need a colon screening before age 45 and having that screening fully covered. So being an advocate for your own health and having a trusted health care provider is crucial. Sonneborn also suggests that you "recruit your GI to assist you in writing a letter of medical necessity."

Low-cost options for the uninsured

For people who are uninsured, colon cancer screening is equally important; it's just less accessible. However, there are options for getting a free or low-cost colonoscopy.

The New York State Cancer Services Program (CSP) provides colon cancer screening to uninsured New Yorkers ages 50 to 75. The Colorectal Cancer Alliance is another resource for accessing either a discounted/low-cost colonoscopy or a no-cost at-home FIT test (fecal immunochemical test). Patients can also consult the Healthcare Bluebook to compare colonoscopy costs in their area. Another option is ColonoscopyAssist, a nationwide organization that provides low-cost colonoscopies in most US cities.

Knowing your medical status can be lifesaving. While you are juggling daily finances and are in great health, screenings like a colonoscopy may not seem like a priority. However, the overall cost of cancer treatment should make every person think twice about delaying screening.

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