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 nervous 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, 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 associate 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 america greater than 15 million instances a yr. Charges of colorectal most cancers are on the rise, notably amongst youthful individuals.
The process, which can also be a advisable screening for individuals 45 or older, includes analyzing the massive 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, stated Glenn Littenberg, a doctor who lately chaired the reimbursement committee of the American Society of Gastrointestinal Endoscopy.
In response to Contos’ medical document, 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 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 possible 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 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 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 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 expenses for a diagnostic colonoscopy and was instructed he’d been despatched a price estimate by 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 massive motive 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 charge 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 worth.
After analyzing Contos’ invoice, Littenberg stated it’s customary 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 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 price of $4,047 was “lots, although not uncommon for giant educational 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 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 instructed Northwestern, ‘I’m not paying that, and I don’t care if you happen to ship me to collections,’” he stated. He filed appeals with the hospital and Aetna however was in the end 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 in keeping with 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 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 fully 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 contemplate going to a freestanding endoscopy heart or ambulatory surgical procedure heart not related to a hospital. A 2023 research 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 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.
Sufferers can also search for a good-faith estimate of the money worth, which may be decrease than the value for sufferers utilizing insurance coverage to pay for a process. As well as, they’ll verify costs by web sites corresponding to Turquoise Well being and Truthful Well being, which draw from federal worth transparency information or claims information from insurers.
Nonetheless, the precise price may very well be larger than the estimate if the colonoscopy finds a number of polyps that must 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 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 ought to be simpler for sufferers, Xiao stated: “You shouldn’t need to 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 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 gotten a complicated or outrageous medical invoice you need to share? Inform us about it!
