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. But he turned more and more frightened when the bleeding continued for weeks.
The Chicago well being care guide contacted his doctor at Northwestern Medicine, who referred him for a diagnostic colonoscopy, not less than partly as a result of Contos, 45, has a household historical past of colon points.
“I work out loads,” he stated. “But my companion stated this is not 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 within the United States more than 15 million times a yr. Rates of colorectal most cancers are on the rise, notably amongst youthful folks.
The process, which can also be a beneficial screening for folks 45 or older, entails inspecting the massive gut utilizing a tube with a video digicam that may additionally gather 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 not too long ago chaired the reimbursement committee of the American Society of Gastrointestinal Endoscopy.
According to Contos’ medical document, the gastroenterologist who carried out his colonoscopy described it as “not tough.” He biopsied and eliminated small growths known as polyps from two spots and recognized massive inner hemorrhoids, that are swollen veins.
The biopsy samples had been despatched to pathology for testing and located to be precancerous. But the gastroenterologist reported discovering no proof of most cancers, and after reviewing the pathology report, he concluded hemorrhoids had been the seemingly explanation for the bleeding.
The remaining invoice
The hospital charged a complete of $19,206 for the process, together with doctor charges. The insurer negotiated the worth 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 worth.) 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 drawback: Colonoscopies that discover polyps price extra
Contos was shocked and offended when he acquired his itemized invoice. “I stated, ‘I do not perceive this.’ Then I began to analysis the associated fee.”
He requested the hospital what it expenses 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 under consideration, listed a complete worth of $7,203, with an out-of-pocket invoice of $2,381. He requested Northwestern why the costs had been practically thrice the estimate and why his out-of-pocket share was practically twice as excessive.
One large 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 first process was listed as “colonoscopy and biopsy,” whereas the second was listed as “colonoscopy w/lesion removing.” Aetna’s negotiated member fee decreased 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 decreased worth.
After inspecting Contos’ invoice, Littenberg stated it is customary 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 wise phrases that anybody might perceive?” Littenberg stated.
Even with that discount, Littenberg stated, he thought Contos’ complete out-of-pocket price of $4,047 was “loads, although not uncommon for big tutorial facilities.”
Contos’ insurance coverage paperwork present Aetna’s negotiated fee for his colonoscopy at Northwestern was greater than twice the insurer’s median negotiated fee for a similar process at different Chicago-area hospitals, in keeping with Forrest Xiao, director of quantitative analysis at Turquoise Health, an organization that gathers well being care worth information.
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 do not 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 in step with different tutorial medical facilities in Chicago and “non-negotiable” — and that his account can be turned over to a collections company.
CVS Health spokesperson Phillip Blando stated in a written assertion to KFF Health News that the claims for Contos had been “paid precisely” by Aetna, declining additional remark. (CVS Health 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 is 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 cheaper price, Littenberg stated, sufferers ought to contemplate going to a freestanding endoscopy heart or ambulatory surgical procedure heart not related to a hospital. A 2023 study discovered that ambulatory surgical procedure facilities billed insurers a median of about $1,030 for a colonoscopy with biopsy or with removing of a polyp, in contrast with $1,760 at a hospital.
Bill of the Month
To get a way of how a lot a diagnostic colonoscopy might price, sufferers can seek the advice of a hospital’s worth web site and an insurer’s cost-estimator web site, each required by federal worth transparency guidelines.
Patients can also search for a good-faith estimate of the money worth, which may be decrease than the worth for sufferers utilizing insurance coverage to pay for a process. In addition, they will test costs via web sites equivalent to Turquoise Health and Fair Health, which draw from federal worth transparency information or claims information from insurers.
Still, the precise price may very well be larger than the estimate if the colonoscopy finds a number of polyps that should be eliminated and biopsied, which happens in not less than 40% of all colonoscopies, Littenberg stated. Patients ought to ask whether or not the worth consists of these probably further providers. After all, the purpose of a diagnostic colonoscopy is to search out and, if mandatory, deal with lesions that might trigger issues — whatever the quantity discovered.
It all must be simpler for sufferers, Xiao stated: “You should not should be a medical billing knowledgeable to know what you are going to pay.”
Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical payments. Since 2018, this sequence has helped many sufferers and readers get their medical payments decreased, and it has been cited in statehouses, on the U.S. Capitol, and on the White House. Do you may have a complicated or outrageous medical invoice you wish to share? Tell us about it!
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This article first appeared on KFF Health News and is republished right here underneath a Creative Commons license.
