Tom Contos is an avid runner. When he began experiencing rectal bleeding in March, he thought train may very well be the trigger and tried to disregard it. However he grew to become more and more fearful when the bleeding continued for weeks.
The Chicago well being care advisor contacted his doctor at Northwestern Drugs, who referred him for a diagnostic colonoscopy, no less than partly as a result of Contos, 45, has a household historical past of colon points.
“I work out so much,” he stated. “However my associate stated this isn’t regular. My main care doctor stated, ‘Given your loved ones historical past, let’s get you in.’”
Northwestern Memorial Hospital requested him to prepay $1,000 out-of-pocket, and he underwent the process in June.
Then the invoice got here.
The Medical Process
Colonoscopies are carried out in the USA greater than 15 million instances a yr. Charges of colorectal most cancers are on the rise, notably amongst youthful folks.
The process, which can be a beneficial screening for folks 45 or older, includes analyzing the massive gut utilizing a tube with a video digicam that may additionally acquire tissue samples.
It usually takes lower than one hour, with one other hour spent taking the affected person’s historical past, administering anesthesia, and monitoring their restoration, stated Glenn Littenberg, a doctor who just lately chaired the reimbursement committee of the American Society of Gastrointestinal Endoscopy.
In accordance with Contos’ medical file, the gastroenterologist who carried out his colonoscopy described it as “not tough.” He biopsied and eliminated small growths referred to as polyps from two spots and recognized giant inner hemorrhoids, that are swollen veins.
The biopsy samples have been despatched to pathology for testing and located to be precancerous. However the gastroenterologist reported discovering no proof of most cancers, and after reviewing the pathology report, he concluded hemorrhoids have been the doubtless reason behind the bleeding.
The Remaining Invoice
The hospital charged a complete of $19,206 for the process, together with doctor charges. The insurer negotiated the value to $5,816 and paid $1,979, leaving a affected person share of $4,047. (It wasn’t clear why the funds added as much as barely greater than the negotiated value.) After Contos had paid $1,000 up entrance, plus $1,381 proper after the process, the hospital stated he nonetheless owed $1,666.
The Billing Downside: Colonoscopies That Discover Polyps Price Extra
Contos was shocked and offended when he obtained his itemized invoice. “I stated, ‘I don’t perceive this.’ Then I began to analysis the associated fee.”
He requested the hospital what it fees for a diagnostic colonoscopy and was advised he’d been despatched a value estimate via his on-line affected person portal previous to the process.
The estimate, which took his deductible of $3,200 into consideration, listed a complete value of $7,203, with an out-of-pocket invoice of $2,381. He requested Northwestern why the fees have been almost 3 times the estimate and why his out-of-pocket share was almost twice as excessive.
One massive cause was revealed in a proof of advantages (EOB) assertion from Contos’ insurance coverage firm, Aetna: Northwestern had charged for 2 colonoscopies, at $5,466 every. And there have been two charges for the gastroenterologist — $1,535 and $1,291.
The primary process was listed as “colonoscopy and biopsy,” whereas the second was listed as “colonoscopy w/lesion elimination.” Aetna’s negotiated member price lowered the primary $5,466 hospital cost to $3,425, whereas the cost for the second process was lowered to $1,787 — $1,638 much less.
Neither the invoice nor the EOB defined why there was a second process listed, at a lowered value.
After analyzing Contos’ invoice, Littenberg stated it’s normal for suppliers to invoice for 2 colonoscopies in the event that they take away two or extra polyps in numerous methods, due to the additional work. As on this case, hospitals usually use a modifier code that reduces the quantity charged for the second billed colonoscopy so that they cost just for the additional work, he added.
“How do you clarify that in smart phrases that anybody may perceive?” Littenberg stated.
Even with that discount, Littenberg stated, he thought Contos’ whole out-of-pocket value of $4,047 was “so much, although not uncommon for giant tutorial facilities.”
Contos’ insurance coverage paperwork present Aetna’s negotiated price for his colonoscopy at Northwestern was greater than twice the insurer’s median negotiated price for a similar process at different Chicago-area hospitals, in line with Forrest Xiao, director of quantitative analysis at Turquoise Well being, an organization that gathers well being care value knowledge.
In exchanges with Northwestern and Aetna representatives, Contos requested why he was charged for 2 colonoscopies. A Northwestern consultant stated that due to the modifier code, he wasn’t really being billed for 2 procedures, which Contos discovered bewildering.
“I advised Northwestern, ‘I’m not paying that, and I don’t care when you ship me to collections,’” he stated. He filed appeals with the hospital and Aetna however was finally advised the billing was right.
The Decision
In an e mail, Contos advised the billing division that its cost was “ridiculously excessive.” A consultant responded that Northwestern’s pricing is consistent with different tutorial medical facilities in Chicago and “non-negotiable” — and that his account could be turned over to a collections company.
CVS Well being spokesperson Phillip Blando stated in a written assertion to KFF Well being Information that the claims for Contos have been “paid precisely” by Aetna, declining additional remark. (CVS Well being owns Aetna.)
Northwestern didn’t reply to a number of requests for remark.
Contos stated he wrote to his doctor that he was regretfully dropping him and leaving Northwestern solely due to the well being system’s excessive pricing.
He stated he’s nonetheless experiencing periodic signs, which he relieves with over-the-counter Preparation H. A one-ounce tube of the ointment prices $10.99 at CVS.
The Takeaway
To get a colonoscopy at a lower cost, Littenberg stated, sufferers ought to take into account going to a freestanding endoscopy middle or ambulatory surgical procedure middle not related to a hospital. A 2023 examine discovered that ambulatory surgical procedure facilities billed insurers a mean of about $1,030 for a colonoscopy with biopsy or with elimination of a polyp, in contrast with $1,760 at a hospital.
To get a way of how a lot a diagnostic colonoscopy may value, sufferers can seek the advice of a hospital’s value web site and an insurer’s cost-estimator web site, each required by federal value transparency guidelines.
Sufferers can also search for a good-faith estimate of the money value, which could be decrease than the value for sufferers utilizing insurance coverage to pay for a process. As well as, they’ll examine costs via web sites comparable to Turquoise Well being and Honest Well being, which draw from federal value transparency knowledge or claims knowledge from insurers.
Nonetheless, the precise value may very well be greater than the estimate if the colonoscopy finds a number of polyps that should be eliminated and biopsied, which happens in no less than 40% of all colonoscopies, Littenberg stated. Sufferers ought to ask whether or not the value consists of these doubtlessly further providers. In spite of everything, the purpose of a diagnostic colonoscopy is to seek out and, if needed, deal with lesions that might trigger issues — whatever the quantity discovered.
All of it needs to be simpler for sufferers, Xiao stated: “You shouldn’t need to be a medical billing knowledgeable to know what you’re going to pay.”
Invoice of the Month is a crowdsourced investigation by KFF Well being Information and The Washington Put up’s Nicely+Being that dissects and explains medical payments. Since 2018, this sequence has helped many sufferers and readers get their medical payments lowered, and it has been cited in statehouses, on the U.S. Capitol, and on the White Home. Do you’ve got a complicated or outrageous medical invoice you need to share? Inform us about it!
