Screening Colonoscopy Incorrectly Billed as Diagnostic

Under U.S. preventive care guidelines, screening colonoscopies should be performed once every 10 years, starting when a person is 45 years old.

Screening colonoscopies for adults aged 45 – 75 are covered as preventive care under all non-grandfathered major medical health plans, which means that you shouldn’t have any out-of-pocket costs associated with the procedure.

As long as you use an in-network facility, all costs associated with a screening colonoscopy should be paid by the health plan, including the bowel preparation drink, the facility fee, the doctor’s fee, and the anesthesiologist’s fee.

(Note that the No Surprises Act protects you from out-of-network charges as long as you use an in-network facility; the term “facility” includes hospitals, hospital outpatient departments, and ambulatory surgery centers.)

But things can get complicated when it comes to colonoscopy billing and coverage because some colonoscopies are considered diagnostic rather than screening, and that means they’ll have out-of-pocket costs.

For a colonoscopy to be considered a screening procedure, you have to be at least 45 years old, not have had a colonoscopy within the last ten years, and have no GI symptoms that prompted the referral for the procedure.

As long as all of those are true, your health plan should fully cover the cost of the procedure. And according to CMS guidelines (see Q5), that is true even if polyps are found and removed during the screening colonoscopy. The health plan cannot impose out-of-pocket costs for a screening colonoscopy just because polyps are found during the procedure.

However, the presence of polyps will most likely mean that your doctor tells you to come back for a follow-up colonoscopy in three or five years (instead of ten years). And that follow-up procedure will not be considered a screening test, since it will have been less than ten years since your last colonoscopy. So you should be prepared to have out-of-pocket costs for the follow-up colonoscopy.

And if your doctor advises that you have a colonoscopy prior to age 45 due to family history, or sends you for a colonoscopy due to GI symptoms, you should expect out-of-pocket costs for the procedure. Even if you’re 45+ and would otherwise be due for a screening colonoscopy, the presence of GI symptoms will result in the procedure being billed as diagnostic rather than screening.

If you’ve had a colonoscopy that was considered a screening procedure, be aware that health plans are not allowed to impose out-of-pocket costs just because polyps were found and removed during the procedure. If you’re our client and are experiencing billing/claims issues associated with this, we can help you sort it out.