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 grew to become more and more frightened 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 least partly as a result of Contos, 45, has a household historical past of colon points.
“I work out rather a lot,” he mentioned. “However my associate mentioned this isn’t regular. My major 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 america greater than 15 million occasions a yr. Charges of colorectal most cancers are on the rise, significantly amongst youthful individuals.
The process, which can be a really helpful screening for individuals 45 or older, entails analyzing the massive gut utilizing a tube with a video digicam that may additionally accumulate 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, mentioned Glenn Littenberg, a doctor who not too long ago chaired the reimbursement committee of the American Society of Gastrointestinal Endoscopy.
In keeping with 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 giant 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 behind the bleeding.
The Ultimate 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 mentioned he nonetheless owed $1,666.
The Billing Drawback: Colonoscopies That Discover Polyps Value Extra
Contos was shocked and indignant when he obtained his itemized invoice. “I mentioned, ‘I don’t perceive this.’ Then I began to analysis the associated fee.”
He requested the hospital what it costs for a diagnostic colonoscopy and was advised 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 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 almost thrice the estimate and why his out-of-pocket share was almost twice as excessive.
One massive 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 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 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 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 smart phrases that anybody might perceive?” Littenberg mentioned.
Even with that discount, Littenberg mentioned, he thought Contos’ complete out-of-pocket value of $4,047 was “rather a lot, although not uncommon for giant 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, in keeping 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 mentioned 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 don’t care should you ship me to collections,’” he mentioned. He filed appeals with the hospital and Aetna however was in the end advised the billing was appropriate.
The Decision
In an electronic mail, Contos advised the billing division that its cost was “ridiculously excessive.” A consultant responded that Northwestern’s pricing is in step with different educational medical facilities in Chicago and “non-negotiable” — and that his account could 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 totally 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 middle or ambulatory surgical procedure middle not related to a hospital. A 2023 examine 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 might 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.
Sufferers can also lookup a good-faith estimate of the money worth, which could be decrease than the worth for sufferers utilizing insurance coverage to pay for a process. As well as, they will examine costs by web sites reminiscent of Turquoise Well being and Honest Well being, which draw from federal worth transparency information or claims information from insurers.
Nonetheless, the precise value could possibly be increased than the estimate if the colonoscopy finds a number of polyps that should be eliminated and biopsied, which happens in at the least 40% of all colonoscopies, Littenberg mentioned. Sufferers ought to ask whether or not the worth contains these probably further companies. In any case, the purpose of a diagnostic colonoscopy is to search out and, if crucial, deal with lesions that might trigger issues — whatever the quantity discovered.
All of it needs to be simpler for sufferers, Xiao mentioned: “You shouldn’t need to be a medical billing knowledgeable to know what you’re going to pay.”
Invoice of the Month is a crowdsourced investigation by KFF Well being Information and The Washington Publish’s Effectively+Being that dissects and explains medical payments. Since 2018, this sequence 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 gotten a complicated or outrageous medical invoice you need to share? Inform us about it!
