Guide to help with patient questions about colonoscopy payments
The cost of health care and all medical services (not just GI procedures and colonoscopy) vary widely between countries, therefore direct cost comparisons between the U.S. and other countries are very difficult. There are many factors that contribute to the cost variance including different insurance systems, different approaches to facility charges and reimbursements, different ways to control costs, the complexity of the health care systems, and differences in cost of living.
What costs will my insurance provider/Medicare cover? Why do I still have to pay for some costs of the colonoscopy?
Reimbursement depends on the patient’s insurance provider and the provider contract. Patients should review their health insurance plan for specific details including if the doctor is within their insurance company’s list of "in-network" providers. If they are not and are considered "out of network," the cost to the patient may be significantly higher.
In 2000, Medicare started paying for colonoscopy for people age 50 and older. The Patient Protection and Affordable Care Act, passed in 2010, waives the coinsurance and deductible for many colorectal cancer screening tests, including colonoscopy. An oversight in the 2010 law still held patients financially responsible for a 20% copay for a screening colonoscopy if a polyp was removed because polyp removal changed the procedure from a "screening" test (which is covered under the Affordable Care Act) to a "therapeutic" exam (polyp removal). Patients with Medicare coverage must still pay a coinsurance (but not a deductible) when a polyp is removed as a result of a screening colonoscopy. The GI societies are working on changing cost sharing for screening colonoscopy for Medicare beneficiaries.
In 2013, the federal government issued an important clarification on preventive screening benefits under the Affordable Care Act. Patients with certain private insurance plans will no longer be liable for cost sharing when a precancerous colon polyp is removed during a screening colonoscopy. This ensures that colorectal cancer screening is available to privately insured patients at no additional cost, as intended by the new health care law. Patients should review their health insurance plan for specific details, including whether their plan falls under this guidance.
Finally, colonoscopies that are performed to evaluate specific problems, such as intestinal bleeding or anemia, are not classified by private insurers and Medicare as screening procedures, and may not be eligible for waiver of deductible and copay requirements.
Can I have a colonoscopy without sedation since anesthesia costs so much?
In many cases, colonoscopy can be done without sedation. However, sedation is used to make patients comfortable during the procedure. Having a colonoscopy with or without sedation may also depend on the individual health of the patient and should be discussed with your doctor. Many patients prefer to be sedated during the exam. Depending on the type of sedation used, there may or may not be an extra charge for this portion of the service. Patients should discuss the available options with their physician and specifically ask about the cost of the various sedation options.
