Colonoscopy Costs and Coverage

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

Preventative screening test for early detection of some cancers is key to the quality of life and surviving the disease. Such tests include mammograms, chest x-rays, annual blood work, and colonoscopies

The Centers for Disease Control and Prevention (CDC) says that colorectal cancer is "expected to cause about 52,580 deaths during 2022," and the agency points out that rates are increasing among people who are younger than 50 years old. 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.

Preventative screening for early detection is key. But how can you get that screening without incurring a huge bill? I had my first colonoscopy in New York City at age 40. The CDC says that the average cost for the procedure in the US is over $3000. Under no circumstances would I have been able to afford that out of pocket.

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Colonoscopy Overview

"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, told Health.

Polyps, Dr. Ganjhu said, 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," added Dr. Ganjhu.

During the colonoscopy procedure, Dr. Ganjhu explained, 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 that 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.
  • The suction port allows the examiner to clean or suction out liquid from the colon.

Mandated Coverage

The CDC currently advises that people who are 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.

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 these tests.

Coverage Under Age 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 a family history of colon cancer or polyps under the age of 45".

For example, Brett C., a management consultant living in Atlanta, told 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. Subsequent screenings for both Brett and his brothers discovered precancerous polyps.

Your medical history will determine whether you need a colon screening before age 45 and whether the screening will be fully covered. So being an advocate for your own health and having a trusted healthcare provider is crucial. Christin Sonneborn, a patient navigator at Colorectal Cancer Alliance, suggests that you "recruit your GI to assist you in writing a letter of medical necessity."

Diagnostic Colonoscopy

A screening colonoscopy is done based on a recommended schedule, not for the evaluation of symptoms.

Dr. Ganjhu explained that a diagnostic colonoscopy, "will be performed on patients exhibiting alarming symptoms, such as bleeding, a change in bowel habits, a change in stool caliber, diarrhea, constipation, abdominal pain, or weight loss".

The payment guidelines for a diagnostic colonoscopy may differ from that of a colonoscopy that's done as part of preventative care.

Surprise Bills

But "guaranteed coverage" can be a slippery concept, and surprise bills are not uncommon. Many insurers use the loophole in how they define "screening" tests to avoid paying for the procedure. Here are a few reasons why you might get an unexpected bill for your screening colonoscopy, and what you can do to avoid surprise bills.

Out of Network Providers

Patients need to 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," Sonneborn told 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," advised Sonneborn.

Bowel Prep

You may be responsible for paying for your bowel prep kit and other services. To get accurate pricing and avoid unexpected costs, obtain the current procedural terminology (CPT) code for your colonoscopy from your healthcare provider. Questions that you should ask your health insurance carrier prior to your colonoscopy include:

  • Are there any out-of-pocket costs for the CPT code being used by the doctor?
  • Is the anesthesiologist being used in the network?
  • Will you save money by scheduling the procedure at an ambulatory surgery center (ASC) versus a hospital outpatient department (HOPD)?

Cost of Complications

Another surprising twist: The colonoscopy might be approved for coverage initially, and then coverage is reversed when precancerous polyps are found. The policy may vary with different payers.

Brett C, who had private insurance, 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 costs, too. Keep in mind that I worked for a Fortune 100 company, and I'd selected the best health insurance options available," said Brett.

  • According to the 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".

Sonneborn adds, "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."

Options For the Uninsured

For people who are uninsured, colon cancer screening is equally important; it's just less accessible. Patients can consult the Healthcare Bluebook to compare colonoscopy costs in their area.

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 a resource for accessing either a discounted/low-cost colonoscopy or a no-cost at-home fecal immunochemical test (FIT).
  • 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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