I’m Afraid to Have a Colonoscopy – Because I Might Get A Bill

A friend of mine was thrilled to finally have health insurance again, after being uninsured for several years. He had gone to see a primary care physician, because although he felt fine, he was smart enough to know that once you reach a certain age, it can be important to have things checked out.
His new physician advised him that at the age of 50, a screening colonoscopy was recommended. My friend was afraid to go, because he worried if they found something (for example, polyps) and removed them, he could be billed. He joked, “Can I tell them that if they find something to leave it there and I can decide what to do about it later?”
He was right to worry, because some providers don’t understand that the usual coding rules don’t apply when it comes to preventative care under the Affordable Care Act. I’ve heard several stories about patients who were erroneously billed – heck, it happened to me once when I went for an annual screening! And it can be difficult and time consuming to try to either convince an uninformed biller or provider of an error, or to get your money back once you’ve overpaid a provider.

The US Department of Health & Human Services has instructed insurers on how to process these claims, and providers need to be sure to bill them correctly.

Here’s what HHS says about my friend’s proposed situation:
Q5: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the USPSTF recommendation, is it permissible for a plan or issuer to impose cost-sharing for the cost of a polyp removal during the colonoscopy?
Answer: No. Based on clinical practice and comments received from the American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and the Society for Gastroenterology Nurses and Associates, 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. On the other hand, a plan or issuer may impose cost-sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.
Complete information can be found here, in The Center for Consumer Information & Insurance Oversight’s Affordable Care Act Implementation FAQs – Set 12.
The bottom line for my friend is that the money is no reason to avoid scheduling this potentially lifesaving screening procedure.


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