Tom Contos is an avid runner. When he began experiencing rectal bleeding in March, he thought train might 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 marketing consultant contacted his doctor at Northwestern Medication, who referred him for a diagnostic colonoscopy, at the very least partly as a result of Contos, 45, has a household historical past of colon points.
“I work out lots,” he stated. “However my accomplice stated this isn’t regular. My major 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 more than 15 million times a 12 months. Charges of colorectal most cancers are on the rise, notably amongst youthful individuals.
The process, which can be a really useful screening for individuals 45 or older, entails inspecting the big gut utilizing a tube with a video digicam that may additionally acquire tissue samples.
It sometimes 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 lately chaired the reimbursement committee of the American Society of Gastrointestinal Endoscopy.
In response to Contos’ medical file, 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 giant inside hemorrhoids, that are swollen veins.
The biopsy samples had 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 had been the doubtless explanation for the bleeding.
The Ultimate 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 Value 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 price.”
He requested the hospital what it prices for a diagnostic colonoscopy and was instructed he’d been despatched a price 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 value of $7,203, with an out-of-pocket invoice of $2,381. He requested Northwestern why the fees had been practically thrice the estimate and why his out-of-pocket share was practically twice as excessive.
One huge purpose 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 removing.” Aetna’s negotiated member charge diminished 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 diminished value.
After inspecting Contos’ invoice, Littenberg stated it’s commonplace 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 sometimes 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 wise 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 “lots, although not uncommon for big tutorial facilities.”
Contos’ insurance coverage paperwork present Aetna’s negotiated charge for his colonoscopy at Northwestern was greater than twice the insurer’s median negotiated charge 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 instructed Northwestern, ‘I’m not paying that, and I don’t care for those who ship me to collections,’” he stated. He filed appeals with the hospital and Aetna however was finally instructed the billing was appropriate.
The Decision
In an e-mail, Contos instructed the billing division that its cost was “ridiculously excessive.” A consultant responded that Northwestern’s pricing is according to different tutorial 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 stated in a written assertion to KFF Well being Information that the claims for Contos had 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 totally 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 cheaper price, Littenberg stated, sufferers ought to take into account 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 mean of about $1,030 for a colonoscopy with biopsy or with removing 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 might 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 similar to Turquoise Health and Fair Health, which draw from federal value transparency knowledge or claims knowledge from insurers.
Nonetheless, the precise value might be larger than the estimate if the colonoscopy finds a number of polyps that have to be eliminated and biopsied, which happens in at the very least 40% of all colonoscopies, Littenberg stated. Sufferers ought to ask whether or not the value consists of these doubtlessly further companies. 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 should be a medical billing professional to know what you’re going to pay.”
Invoice 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 collection has helped many sufferers and readers get their medical payments diminished, and it has been cited in statehouses, on the U.S. Capitol, and on the White Home. Do you’ve a complicated or outrageous medical invoice you wish to share? Tell us about it!
