Colonoscopy Costs and Coverage

Preventative screening tests are key to the early detection of some cancers, which means they can improve your chances of 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 people—particularly Black families—hard. 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? The CDC says that the average cost for the procedure in the US is over $3000. Many people are unable to afford that out of pocket.

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, a gastroenterology specialist in New York City, told Health.

Polyps, said Dr. Ganjhu, 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, a gastroenterologist passes a tube into the rectum, explained Dr. Ganjhu; 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, while 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 people 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. People younger than 45 might need to receive a colonoscopy if they have risk factors such as the following:

• A family history of colon cancer or polyps
• A personal history of colon cancer or polyps
• A personal history of inflammatory bowel disease
• A personal history of radiation to the abdomen or pelvic area to treat cancer

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, suggested 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 who have "alarming symptoms" such as:

• Bleeding
• A change in bowel habits or stool caliber
• Diarrhea
• Constipation
• Abdominal pain
• 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

"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 charges.

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."

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 healthcare provider?
• Is the anesthesiologist being used in the network?
• Will I 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, only for that coverage to be reversed when precancerous polyps are found. The policy may vary with different payers.

Brett, 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."

The Centers for Medicare and Medicaid Services (CMS) states that "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 healthcare provider 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 explained 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."

And this is fair, according to Sonneborn. "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," added Sonneborn.

Options for People Who Are 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).
• ColonoscopyAssist is 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.

A Quick Review

Getting a colonoscopy can detect colorectal cancer early, which can help maximize your chance of survival if you have the disease. Experts recommend that most people start colorectal cancer screening at the age of 45 and that people who belong to high-risk groups start screening even earlier.

Making sure that all providers (including anesthesiologists) are in-network and that you are advocating for yourself, asking questions as necessary, and being aware of your options (whether you're insured or not), as these are all steps you can take to minimize your colonoscopy costs.