Tom Contos is an avid runner. When he began experiencing rectal bleeding in March, he thought train could possibly be the trigger and tried to disregard it. However he turned more and more fearful when the bleeding continued for weeks.
The Chicago well being care guide contacted his doctor at Northwestern Drugs, 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 lots,” he mentioned. “However my associate mentioned this isn’t regular. My main care doctor mentioned, ‘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 12 months. Charges of colorectal most cancers are on the rise, significantly amongst youthful folks.
The process, which can be a really useful screening for folks 45 or older, entails inspecting the big gut utilizing a tube with a video digital camera that may additionally accumulate 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, mentioned Glenn Littenberg, a doctor who just lately chaired the reimbursement committee of the American Society of Gastrointestinal Endoscopy.
In line with Contos’ medical report, 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 massive 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 probably reason 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 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 mentioned he nonetheless owed $1,666.
The Billing Drawback: Colonoscopies That Discover Polyps Value Extra
Contos was shocked and offended when he acquired his itemized invoice. “I mentioned, ‘I don’t perceive this.’ Then I began to analysis the associated fee.”
He requested the hospital what it expenses for a diagnostic colonoscopy and was informed 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 costs have been practically 3 times the estimate and why his out-of-pocket share was practically twice as excessive.
One huge cause was revealed in an evidence 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 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 value.
After inspecting Contos’ invoice, Littenberg mentioned it’s normal for suppliers to invoice for 2 colonoscopies in the event that they take away two or extra polyps in several 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 in order that they cost just for the additional work, he added.
“How do you clarify that in smart phrases that anybody may perceive?” Littenberg mentioned.
Even with that discount, Littenberg mentioned, he thought Contos’ complete out-of-pocket price of $4,047 was “lots, although not uncommon for big educational 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, based on Forrest Xiao, director of quantitative analysis at Turquoise Well being, an organization that gathers well being care value information.
In exchanges with Northwestern and Aetna representatives, Contos requested why he was charged for 2 colonoscopies. A Northwestern consultant mentioned that due to the modifier code, he wasn’t truly being billed for 2 procedures, which Contos discovered bewildering.
“I informed Northwestern, ‘I’m not paying that, and I don’t care if you happen to ship me to collections,’” he mentioned. He filed appeals with the hospital and Aetna however was finally informed the billing was right.
The Decision
In an e mail, Contos informed the billing division that its cost was “ridiculously excessive.” A consultant responded that Northwestern’s pricing is according to different educational medical facilities in Chicago and “non-negotiable” — and that his account can be turned over to a collections company.
CVS Well being spokesperson Phillip Blando mentioned 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 mentioned he wrote to his doctor that he was regretfully dropping him and leaving Northwestern completely due to the well being system’s excessive pricing.
He mentioned 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 cheaper price, Littenberg mentioned, 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 median 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 price, 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 lookup a good-faith estimate of the money value, which may be decrease than the value for sufferers utilizing insurance coverage to pay for a process. As well as, they will examine costs via web sites reminiscent of Turquoise Well being and Honest Well being, which draw from federal value transparency information or claims information from insurers.
Nonetheless, the precise price could possibly 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 mentioned. Sufferers ought to ask whether or not the value contains these probably additional 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 must be simpler for sufferers, Xiao mentioned: “You shouldn’t must be a medical billing professional to know what you’re going to pay.”
Invoice of the Month is a crowdsourced investigation by KFF Well being Information and The Washington Submit’s Effectively+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 Home. Do you have got a complicated or outrageous medical invoice you need to share? Inform us about it!
