Health Insurance/Colonoscopy Help Needed

Exactly what I'm worried about. When I called the office before canceling the one I had scheduled they said that they couldn't even give an estimate total cost since certain things like the facility and anesthesia would be billed separately from the doctor doing the procedure. It's absurd

Most Insurance Companies pay for colonoscopies as preventive care every 7 years but at 29 you are probably too young.

You must be having some issues the Dr wants to check

You may ask if he would let you do a Cologuard

Cologuard test is not as effective as a colonoscopy. Detecting and removing polyps is critical to colon cancer prevention, and Cologuard only detects large precancerous polyps 42% of the time. A colonoscopy detects the same polyps 95% of the time and they are removed during the same procedure.

The cost of the Cologuard is $599. This includes cost of shipping the kit to your home and the return shipping of back costs.

It sucks that healthcare and insurance has to be as convoluted as it is.

A couple things: It's very possible that you can find a non-insurance/cash pay price that's cheaper than what your insurance costs would be. The downside to this is potential additional costs (pathology from biopsies etc.) that you could be hook for or if there's anything positive on the scope that would require further management then none of the scope costs would apply to your deductible and you would still incur these costs.

As far as getting an accurate estimate, you can ask your GI doc what CPT code and ICD10 code that they are planning to use (granted the CPT code can change if they have to do more than just a diagnostic study), you can use this CPT and ICD 10 code and either call your insurance company to try to get an estimate cost of the procedure.

Other option is that most facilities do price estimates. You should be able to call the OLOL facilty in your town with the CPT and ICD 10 and they should be able to give an estimate as well.

Doing the above would at least give you the facility and GI doc costs and you would just be the anesthesia services that would be harder to predict.

If you are worried about network vs out of network on the ancillary attendees during the procedure try someone like an Ochsners where everything is I house

I had a questionable cat scan back in 2020. Went through Ochsners since my oncologist was through Ochsners. I had $750 deductible then 80/20 till $2250. Think I paid around $1200 all in with doc/hospital/ect

Thankfully what was suspicious on cat scan was just diverticulitis

Reading this thread has reminded me just how abysmal the healthcare system is in the United States. Why we put up with this shite is beyond me.

Wasn't a bill passed just this year in Washington that would prevent this kind of mess? Sorry if I am missing something here...

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You may ask if he would let you do a Cologuard

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If you’re 29 and your doctor wants you to do a cologuard, you should see another doctor.

Unfortunately, you’re trying to be financially responsible in a convoluted system of variables.


You will generally get a bill from:
1) the facility
2) anesthesia
3) the doctor
4) any combination of the 3

Here’s where it becomes fairly annoying:
The bill, the cost, and the reimbursement aren’t really related to each other at all.


-The bill is a made up number. They will happily give it to you. No one pays it. Don’t ever pay the full amount billed. Call someone first. There’s some reasoning for it (basically they’re legally required to charge everyone the same amount (but insurance discounts are acceptable so cash discounts are acceptable)).

-the cost. You will never find this number. But it’s probably pretty close to the cash rate. You can ask each of the 1-3 groups you’ll be getting a bill from for the cash price rather than the traditional fee schedule published price. They’ll generally give you a discount. The discount should be relatively cheap for you compared to the original number while still making money for them.

-the reimbursement (from the insurance company). This one is extremely variable. For the same CPT code, Humana may reimburse 1/2 the amount, BCBS may reimburse 100% of the amount, CIGNA may be 75% or the amount, and Aetna may not reimburse at all (none of these are representations of any specific scenario or one company’s rates relative to another). So generally, you’ll need the CPT code that is going to be charged ahead of time (for colonoscopy, there are 15 total CPT codes (excluding MCR G codes), but there are usually 4ish that are more common than the rest, and the reimbursement isn’t generally hugely different among them), and then you’ll need to call your insurance company and find out their max allowable and whether the provider of the service (endoscopist, anesthetist, hospital) are in network or out of network. If they’re all in network, then you should generally prepare for the max allowable to be what you’re paying, then, of course, subject to your deductible/copay.

There’s no reason (other than your time and sanity), that you can’t get the cash price and the codes and run the numbers and choose what’s cheaper. There’s no reason you can’t pay the cash price then go file the claim yourself with the insurance company if it is cheaper and you want the amounts applied to your deductibles/MOOP (though when done this way, i am fairly certain it is considered out of network, but I am not sure of that. I know that it can be done. I have never done it and don’t generally have any stories of people doing it that way).


Congratulations. If you have made it this far, you’re probably as fed up as I am. I started to look up the cash price at Surgery Center of Oklahoma (cash only hospital that publishes non-negotiable cash prices and helps facilitate payment plans), but they don’t appear to offer endoscopy (likely because the majority of it falls under “screening” and the demand for cash-endoscopy is likely low, as there is a mandate (albeit $0 penalty for the last few years) that everyone have insurance and all insurance cover screenings at no cost to the patient. What I did come across is Endoscopy Assist which has suggested the cost is probably near $2500 on average. I include this to point out that I forgot an entirely new, different bill:
Pathology
You may or may not need a biopsy (or seven). If you do, you’ll have to also pay the pathologist and go through the same rigmarole as above. I’m rather unfamiliar with pathology practices. How they bill for biopsy of tissue vs polyp , the size of the specimens, the number of specimens, etc I have no idea. But. There’s another group to get involved with some of the time in the same process as above.

If you have a family history of colon cancer you can get one for no out of pocket cost. I’ve gone one next week. The key is that your doctor codes it as a screening not a diagnostic.

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I’m rather unfamiliar with pathology practices.

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Not cheap. The pathologist that performed services in my case found the need to perform additional “services”, all of which added to the bill, on some samples under the pretense that the first test was inconclusive. Final results were all negative for anything concerning. Certainly feels like a racket, but what can you do?