Colonoscopy Cost with Private Insurance

 

How much an insurance provider will pay toward a colonoscopy all depends on how the procedure is coded. Medical codes are used to describe diagnoses and treatments and help determine costs and reimbursements. A screening colonoscopy is coded and covered differently than a diagnostic colonoscopy. 

 

Cost of Screening vs. Diagnostic Colonoscopy

A screening colonoscopy is a colonoscopy performed on an asymptomatic (no symptoms) patient of screening age to examine for colon polyps or cancer.

Providers should cover screening colonoscopies as part of Affordable Care Act (ACA) preventive health care, but there are certain conditions that have to be met. Click here to use our simple infographic to find out whether you are eligible for a free or low-cost colonoscopy. Everyone, no matter their history, should be screened starting at age 45. African Americans are at a higher risk and should start sooner. If you have a first-degree relative who has been diagnosed with colon cancer or polyps, it is important to be screened earlier. Please refer to "Family History Could Cover Your Colonoscopy."

Before scheduling your screening colonoscopy, you should make a list of questions to ask your insurance provider to help determine your financial responsibility. Some of these questions should include, but are not limited to:

I am _________ years of age. Am I eligible for a screening colonoscopy under my current policy? NOTE: Most plans will offer colonoscopy benefits at 50 years of age. If you have a family history of colon cancer or polyps, you will have to provide the age of the first-degree relative at the time of diagnosis and ask for the information to be noted in your medical records.

Is Dr. ______________ (your preferred physician) in-network and covered under my policy? What percent?

Is ______________ (your preferred ambulatory surgery center or hospital) in-network and covered under my policy? What percent?

Do I have out-of-pocket costs for anesthesia? (Some providers will waive deductibles and co-insurance for anesthesia costs, but you should ask your provider during this phone call).

If I have a polyp, are the pathology costs covered?

Depending on your plan, most insurance companies pay for the actual screening procedure at 100 percent. However, if you have anesthesia or pathology, there may be cost-sharing involved. This depends entirely on your individual plan. Even if you have no personal or family history of colon cancer or polyps and this is your baseline colonoscopy, it's important to ask your provider about medical coverage if a polyp is found and needs to be removed. Remember, more than 80 percent of colon cancer cases are individuals with no family history of polyps or colon cancer.

A diagnostic colonoscopy is a procedure that is requested when symptoms are present or when another screening procedure comes back positive. Diagnostic colonoscopies are not addressed under the Affordable Care Act, so it is imperative that you call your insurance provider to inquire about coverage and out-of-pocket expenses. You will ask your insurance provider the same questions listed above, but you will want to request information about your financial responsibility for the procedure itself as well as anesthesia and polyp removal (if required) and if you need further care.