Under the Patient Protection and Affordable Care Act, also nicknamed “Obamacare”‘s , most insurance plans are required to cover all costs for preventive care, including colon cancer screenings at 100%. Therefore, Jax thought his colonoscopy would be free. Of course he had some doubts, so he called his insurance company prior to having the colonoscopy done just to be sure. Jax was told it would be covered 100 percent, with no copayment from him and no charge against his deductible. So Jax had the procedure done. Then the bill arrived: $1,100
How can this happen?! Because of a “loophole” in the insurance system, what starts out as a preventive screening may turn into a diagnostic procedure (i.e. if samples are removed for closer examination or polyps are removed during the colonoscopy), which allows your insurance company to bill you. Or if your doctor orders you to have a colonoscopy because of a medical concern, it no longer falls under the preventive care provision.
How will you know what you owe?
Gather your personal coding information
Obtain the preoperative CPT and diagnosis codes as well as the facility name from your provider.
Call your insurance carrier and verify the benefits and coverage by asking the following questions. ( You will need to give the insurance representative your preoperative CPT and Diagnosis codes.)
1. Is the procedure and diagnosis covered under my policy? Yes No
2. Will the diagnosis code be processed as preventative, surveillance, or diagnostic and what are my benefits for that service? (Benefits vary based on how the insurance company recognizes the diagnosis).
Diagnostic/Medical Necessary Benefit:
Deductible: _____________ Coinsurance Responsibility: ___________
Facility in Network: Yes No
Preventative/Wellness/Routine Colonoscopy Benefits:
Are there age and/or frequency limits for my colonoscopy? (e.g. one every ten years over the age of 50, one every two years for a personal history of polyps beginning at age 45, etc) No Yes if so; ______________
Deductible: _____________ Coinsurance Responsibility: _______________
3. If the physician removes a polyp, will this change my out of pocket responsibility? No Yes
Representative’s Name: _________ Call Reference #: _________ Date: ____
Make sure you understand the confusion around this screening or you too could end up with a surprise bill.
