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 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 Medicine, who referred him for a diagnostic colonoscopy, no less than partly as a result of Contos, 45, has a household historical past of colon points.
“I work out a lot,” he mentioned. “But my partner said this isn’t normal. My primary care physician said, ‘Given your family history, 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 Procedure
Colonoscopies are carried out within the United States more than 15 million times a 12 months. Rates of colorectal most cancers are on the rise, notably amongst youthful folks.
The process, which can be a advisable screening for folks 45 or older, includes analyzing the massive gut utilizing a tube with a video digital camera that may additionally acquire 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 lately chaired the reimbursement committee of the American Society of Gastrointestinal Endoscopy.
According to Contos’ medical file, the gastroenterologist who carried out his colonoscopy described it as “not difficult.” 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 have 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 have been the seemingly reason behind the bleeding.
The Final Bill
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 mentioned he nonetheless owed $1,666.
The Billing Problem: Colonoscopies That Find Polyps Cost More
Contos was shocked and offended when he obtained his itemized invoice. “I said, ‘I don’t understand this.’ Then I started to research the cost.”
He requested the hospital what it costs for a diagnostic colonoscopy and was informed he’d been despatched a price estimate by way of his on-line affected person portal previous to the process.
The estimate, which took his deductible of $3,200 into consideration, listed a complete worth of $7,203, with an out-of-pocket invoice of $2,381. He requested Northwestern why the fees have 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 first process was listed as “colonoscopy and biopsy,” whereas the second was listed as “colonoscopy w/lesion removal.” 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 worth.
After analyzing Contos’ invoice, Littenberg mentioned 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 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 explain that in sensible terms that anyone could understand?” Littenberg mentioned.
Even with that discount, Littenberg mentioned, he thought Contos’ whole out-of-pocket value of $4,047 was “a lot, though not rare for large academic centers.”
Contos paid a charge up entrance, then made one other cost after his process. He was shocked and offended when he acquired his itemized invoice displaying he nonetheless owed extra.(Taylor Glascock for KFF Heath News)
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 Health, an organization that gathers well being care worth knowledge.
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 really being billed for 2 procedures, which Contos discovered bewildering.
“I told Northwestern, ‘I’m not paying that, and I don’t care if you send me to collections,’” he mentioned. He filed appeals with the hospital and Aetna however was in the end informed the billing was right.
The Resolution
In an e mail, Contos informed the billing division that its cost was “ridiculously high.” A consultant responded that Northwestern’s pricing is consistent with different tutorial medical facilities in Chicago and “non-negotiable” — and that his account could be turned over to a collections company.
CVS Health spokesperson Phillip Blando mentioned in a written assertion to KFF Health News that the claims for Contos have been “paid accurately” by Aetna, declining additional remark. (CVS Health 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 solely 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 lower cost, Littenberg mentioned, 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 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 value, 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 value for sufferers utilizing insurance coverage to pay for a process. In addition, they’ll test costs by way of web sites comparable to Turquoise Health and Fair Health, which draw from federal worth transparency knowledge or claims knowledge from insurers.
Still, the precise value may very well be greater than the estimate if the colonoscopy finds a number of polyps that should be eliminated and biopsied, which happens in no less than 40% of all colonoscopies, Littenberg mentioned. Patients ought to ask whether or not the value consists of these probably further companies. After all, the purpose of a diagnostic colonoscopy is to search out and, if obligatory, deal with lesions that might trigger issues — whatever the quantity discovered.
It all ought to be simpler for sufferers, Xiao mentioned: “You shouldn’t have to be a medical billing expert to know what you’re 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 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 House. Do you’ve gotten a complicated or outrageous medical invoice you wish to share? Tell us about it!
Harris Meyer:
@Meyer_HM
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