As policies around billing colonoscopies continue to change, it remains clear patients and physicians have trouble navigating the process.
A study published in JAMA Network Open in December looked at out-of-pocket costs for colonoscopies after noninvasive colorectal cancer screenings. It used data from 88,000 people with commercial insurance and Medicare coverage who had a stool-based test. Of those people, 15.8 percent had colonoscopies after the noninvasive screenings and 57.8 percent had at least one polyp removed during their colonoscopy.
Patients with commercial insurance had to pay 48.2 percent of their bill out of pocket, and patients with Medicare had to pay 77.9 percent. The patients who had polyps removed paid more than those who did not.
Private insurers are required to cover colonoscopies following a stool-based screening test with positive results. However, billing practices are not always straightforward.
Hospitals and providers can change preventive billing codes to a diagnostic one, which is more expensive, if a colonoscopy is deemed diagnostic rather than preventive. Polyp removal is at times cited as a reason for the change, though CMS states that polyp removal is part of screening colonoscopies.
Gastroenterologists also run into roadblocks because of declines in reimbursements for colonoscopies for Medicare and Medicaid patients.
"Especially if the procedure is complex and prolonged, we are left with a situation where [the reimbursement] just about covers the overhead costs," Curuchi Anand, MD, a gastroenterologist affiliated with UMass Memorial Health in Worcester, Mass., told Becker's on April 26. "I still continue to provide care as a service to the patients but in the future may need to stop or limit access to these patients."
In the end, the lack of clarity around colonoscopy billing puts patients and gastroenterologists in a tough spot.
"All too often, we see patients who have signs and symptoms, sometimes with ominous features, that need endoscopic evaluation," Alejandro Pruitt, MD, gastroenterologist at GI Consultants of San Antonio, told Becker's on June 10. "Unfortunately, patients are penalized with deductibles that are obscenely high or coinsurance which they cannot afford. Many are lost to follow up when they are informed of their financial responsibility despite our efforts to try and arrange for less costly, and often less sensitive, noninvasive tests."