Her first colonoscopy cost her $0. His second cost $2,185. Why?


Elizabeth Melville and her husband gradually hike the 48 mountain peaks that rise to 4,000 feet in New Hampshire.

“I want to do everything I can to stay healthy so I can ski and hike in my 80s – hopefully even 90!” said the 59-year-old part-time ski instructor who lives in the vacation town of Sunapee.

So when her primary care doctor suggested she get screened for colorectal cancer in September, Melville dutifully prepared for her colonoscopy and went to the outpatient department of New London Hospital for the procedure at no cost. .

Typically, screening colonoscopies are programmed every 10 years from age 45. But more frequent screenings are often recommended for people with a history of polyps, as polyps can be a precursor to malignancy. Melville had had a benign polyp removed during a colonoscopy nearly six years earlier.

Melville’s second test was similar to the first: normal, except for a small polyp that the gastroenterologist removed while she was sedated. It was also benign. So she thought she was done with many patients’ least-appreciated medical obligation for several years.

Then the bill came.

The patient: Elizabeth Melville, 59, who is covered by a Cigna health plan that her husband obtains through his employer. It has an individual deductible of $2,500 and coinsurance of 30%.

Medical service: A screening colonoscopy, including the removal of a benign polyp.

Service provider: New London Hospitala 25-bed facility in New London, NH, which is part of the Dartmouth Health system, a nonprofit academic medical center.

Total bill: $10,329 for the procedure, the anesthesiologist and the gastroenterologist. Cigna’s negotiated rate was $4,144 and Melville’s share under his insurance was $2,185.

The Affordable Care Act made preventative health care such as mammograms and colonoscopies free for patients with no cost sharing. But there is wiggle room as to when a procedure was performed for screening purposes versus a diagnosis.

Getting screened regularly for colorectal cancer is one of the most effective tools people have to prevent it.

The United States Preventive Services Task Force, a nonpartisan group of medical experts, regularly recommend colorectal cancer screening for people at average risk aged 45 to 75.

Colonoscopies can be categorized as for screening or for diagnosis. The former generally incurs no cost to patients under the ACA; the latter can generate invoices.

The Centers for Medicare & Medicaid Services have clarified many times over the years that under the provisions of the ACA on preventive services, the removal of a polyp during a screening colonoscopy is considered an integral part of the procedure and should not alter the cost-sharing obligations patients.

More than 40% of people over 50 have precancerous polyps in the colonaccording to the American Society for Gastrointestinal Endoscopy.

Someone with a higher than average cancer risk may face higher bills and not be protected by law, said Anna Howard, policy manager at the American Cancer Society’s Cancer Action Network.

Having a family history of colon cancer or a personal history of polyps increases a person’s risk profile, and insurers and providers could charge fees based on this. “From the beginning, [the colonoscopy] could be considered diagnostic,” Howard said.

Additionally, getting a screening colonoscopy earlier than the recommended 10-year interval, as Melville did, could open someone up to cost-sharing fees, Howard said.

Coincidentally, Melville’s 61-year-old husband had a screening colonoscopy at the same facility with the same doctor a week after his procedure. Despite her family history of colon cancer and a previous colonoscopy just five years earlier due to its high risk, her husband did not charge anything for the test. The main difference between the two experiences: Melville’s husband didn’t have a polyp removed.

Resolution: When Melville received notices that she owed $2,185, she called Cigna and a representative told her that the hospital had changed the billing code for her procedure from screening to diagnostic. A call to Dartmouth Health’s billing department confirmed this explanation: she was told she was billed because she had a polyp removed, making the procedure more preventative.

Dartmouth Health declined to discuss Melville’s case with Kaiser Health News even though it gave permission to do so.

After KHN’s investigation, Melville was contacted by Joshua Compton of Conifer Health Solutions on behalf of Dartmouth Health. Compton said the diagnostic trouble codes were inadvertently deleted from the system and Melville’s claim is being reprocessed, Melville said.

Cigna also investigated the allegation after being contacted by KHN. Justine Sessions, a spokesperson for Cigna, said: “This issue was quickly resolved as soon as we became aware that the vendor had submitted the claim incorrectly. We have reprocessed the claim and Ms. Melville will not be responsible. disbursements.

Take-out:

Before undergoing an elective procedure such as a cancer screening, it’s always a good idea to try to identify cover minefields, Howard said.

“Contact the insurer before the colonoscopy and say, ‘Hey, I just want to understand what the coverage limits are and what my out-of-pocket expenses might be,'” Howard said. Billing for an anesthesiologist – who simply delivers a dose of sedative – can also become an issue when screening for colonoscopies. Ask if the anesthetist is in network.

Know that doctors and hospitals are required to give good faith estimates of expected patient costs ahead of scheduled procedures under the No Surprises Act, which took effect this year.

Take the time to read all the documents you need to sign and prepare your antennas for problems. And ask to see the documents in advance.

Kaiser Health News is a national newsroom that covers health issues.

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