Colonoscopy Screenings: Free to Patients?

Wednesday, April 30, 2014
Amy Fasti
Physician Endoscopy

Many patients struggle to understand the various rules relating to health care costs. As deductibles and overall patient liability rise, patients must work to determine the health care needs that are most important and work within their financial realities. But there’s good news on the colonoscopy front—screenings are most likely covered under your plan as a free service to patients, with insurance paying the bill!

The Patient Protection and Affordable Care Act (PPACA), which became effective January 1, 2011, requires commercial health care insurance plans to cover preventive services—without any cost sharing—for patients between the ages of 50 and 75. However, confusion remains since PPACA was passed. With the right information, most patients who fit the criteria for a screening colonoscopy may now get one with no out-of-pocket cost. Patients should always contact their insurance carrier prior to any procedure to verify benefits and potential costs, even if their provider does the same.

Some plans consider a colonoscopy for a patient with a personal history, and sometimes a family history, a diagnostic procedure rather than a screening, and therefore may not waive the patient financial responsibility. If the plan is out-of-network with the provider, benefits may not follow PPACA, which could result in cost to the patient. Self-funded plans or those that fall into a “grandfathered” status do not have to follow the PPACA guidelines. So there are many rules and loopholes for payers—it can leave patients scratching their heads wondering where they fit in.

The good news is that most plans do fall under the guidelines of PPACA. Patients between the ages of 50 and 75 who are due for a screening colonoscopy, and that have no other symptoms related to a need for a colonoscopy (e.g. rectal bleeding, abdominal pain), will most likely be covered with no patient financial responsibility. Regardless of the outcome of the screening procedure (e.g. biopsy, polyp removal), no additional cost should be allocated to the patient.

Insurance companies, while in the business of paying for health care services, look for ways to save money by passing on costs to the patients. Therefore, patients and providers should be vigilant in the insurance claims process and pay properly.

The best weapon—verification of benefits—happens before a patient steps into the surgery center for the procedure. It’s crucial the provider and patient have a common understanding of the purpose of the procedure. If a patient believes the procedure is scheduled as a screening, but the provider schedules the case with an understanding that there are symptoms, the mismatch will result in a different outcome than expected. While the physician must indicate any relevant symptoms for the procedure, the patient must then understand the financial implications, as this case would be considered diagnostic and not a screening.

However, effective communication between the physician and patient will help both parties understand the nature of the procedure. In the event a patient is left with a financial liability due to a screening procedure, the patient should contact both the provider and the insurance company. If benefits were verified in advance and the claim was submitted properly, there should be no surprises. Insurance companies process claims incorrectly every day, so patients and providers can and should fight incorrectly processed claims.

Medicare, unfortunately, does not follow the same guidelines as commercial payers. Medicare will pay a screening colonoscopy in full, with no patient cost, when the procedure does not result with a diagnostic maneuver, like a biopsy. In this case, the Medicare patient will have to pay 20% co-insurance, but if they have any deductible left for the year, that portion will be waived. However, Medicare deductibles are so small (less than $200/year), the patient most likely will be paying the same as a patient who was scheduled for a diagnostic procedure.

Ironically, this Medicare protocol may actually be costing the health care system more. There is simply no way for a patient or physician to know what they will do in the course of colonoscopy screening procedure. The point is to prevent colon cancer. But this fear of the unknown may actually be obstructing Medicare patients from being screened. A percentage of these unscreened Medicare patients will have cancer that will create higher costs to the health care system, as well as the obvious negative health consequences for the patients.

Overall, the steps being taken through PPACA and even CMS to promote colon cancer screenings is evidenced by the attempts to minimize cost implications for patients. The bottom line regarding coverage and liability is for patients and providers to verify and understand benefits for each specific case. Screening colonoscopies may save patients cash, and potentially their lives.

Stay tuned for the release of PCC’s next Issue Brief, which will look at health coverage updates and how the Affordable Care Act can improve colonoscopy screening rates. Visit for updates.