You have made one of the most important decisions you will ever make: you are getting a colonoscopy! Your doctor has recommended this important procedure, and now it’s time for you to take some action. The next step is for you to call your insurance company to see if you have any cost-sharing responsibilities. A screening colonoscopy can be fully or mostly covered under the Affordable Care Act depending on your insurance plan. Coverage is not always clear, and it is certainly not the same across the board. Before you have your colonoscopy, it is your responsibility to find out how much the procedure will cost.
Call Your Insurance Provider Before Your Colonoscopy
How should you approach this phone call? What are the correct questions to ask? Here is a sample dialogue to use as a guideline as you speak to your insurance provider to estimate your out-of pocket cost for your upcoming colonoscopy:
Patient: "I am ____ years old and my doctor wants me to get a colonoscopy." (The recommended age for a colonoscopy is age 50 unless you are at high risk)
- Provider: "Who is the surgeon or gastroenterologist who will be performing the procedure? What is the name of the hospital or ambulatory surgery center where you will have the procedure? I would like to check to see if your doctor and facility are in-network." (This information will help your provider tell you how much your procedure will cost for an in-network doctor and facility vs. an out-of-network doctor and facility. Your provider can also direct you to a list of in-network doctors and facilities to save you money.)
Patient: "Am I subject to a deductible for this procedure? What percentage of the procedure is my responsibility?"
- Provider: "To answer those questions, I need to ask you a few questions: Is this your first colonoscopy? Are you having problems? Did your doctor refer to this procedure as a screening colonoscopy or a diagnostic colonoscopy?" (A screening colonoscopy is when there are no symptoms or perceived problems. A diagnostic colonoscopy is associated with symptoms).
Patient: "If I have come in for a screening colonoscopy and my doctor finds a polyp, how might this affect my cost-sharing responsibility?"
- Provider: "That is a great question. Let me look at your plan so I can give you details on your surgery benefits. If a polyp is found and removed during a screening colonoscopy, you may responsible for the cost of the removal and pathology."
Patient: "If I add up these charges, will that give me the exact amount I am paying?"
- Provider: "This is just an estimate of the charges for your colonoscopy. The final cost is determined by how the procedure is billed and whether the colonoscopy is coded as a screening or a diagnostic colonoscopy."
Patient: "Can you direct me to the place on your website that will go over these details we just spoke about so I can refer to my benefits later?" (You always want to be able to access this information again. Having a representative explain your benefits is very important so you understand the charges, but you need to be able to find a copy of your colonoscopy benefits and even print them off for your reference).
Final Cost is Determined by Your Doctor
Remember that the type of colonoscopy you have (diagnostic or screening) and how your procedure is coded is up to your doctor and not your insurance company. Your insurance company is somewhat limited in its ability to tell you what your out-of-pocket cost will be because it is the doctor’s office that applies specific codes to the procedures. Therefore, it is best to view this call as a rough estimate of your cost-sharing responsibility. It is a very good idea to call your doctor's office or facility to confirm costs and how they will code your procedure based on your patient information.
A colonoscopy is one of the best steps that you can take for your health. Because colonoscopies are the most effective test for preventing and diagnosing colon cancer, they carry the highest price tag. However, screening colonoscopies may be free or prove to be very reasonable when you ask the right questions. Call your insurance provider before you schedule your colonoscopy so you can verify that:
- Your doctor is in-network
- Your facility is in-network
- You have colonoscopy screening benefits
- You understand how various outcomes of your colonoscopy will affect your cost-sharing responsibilities.