Colonoscopy preventative care costs

[Guest Benny Guy]

I believe colonoscopy screening for patients 50 yrs and older are covered as a preventative service under PPACA. However, what about a colonoscopy screening that reveals a polyp and the polyp is removed, without patient consent, then the procedure is billed in full because it is now a surgery and not a preventative screening. Is that legit? I'm having a tough time finding the particulars of how this should be billed under PPACA.

[Guest matthew222]

I don't believe the removal of a polyp would fall under preventive services. While I'm not an expert when it comes to polyps, I'm assuming this individual would have gotten it removed even if he was in a position to consent?

[GMK]

the polyp is removed, without patient consent

Really? I'd be surprised if the consent is not in the pre-procedure paperwork that the patient signed. I recall that these papers include statements like 'if you die, it isn't our fault' and 'if we find something, we're gonna take it out' and like that.

And I'm no help otherwise, either, but in this case, I'd argue that the screening is still a screening, whose purpose is to find suspicious stuff. Removal of the polyp is a separate procedure, for which I suppose the greedy b***ds could charge you.

Was the patient advised (or did the patient have reasonable access to information to know) that the whole procedure would be regarded as a surgery, and none of it would be considered a screening, if they found and removed a polyp? Did the patient have the opportunity to choose to have any polyps that were found left in place, to decide later whether to have them removed?

This is a reminder to all of us that it is always a good idea to call the insurer to confirm in detail what's covered before you have any procedure done.

[Guest matthew222]

I'm with you GMK. If you have stomach surgery and the surgeon happens to see a screwdriver next to your liver, he isn't going to stitch you up and ask you afterwards if you wanted it removed. Something like this would would almost have to be spelled out in the pre-surgery paperwork. I don't think the covered member is going to have a leg to stand on if he or she appeals the claim.

[GBurns]

I guess a lot depends on whether the plan is grandfathered or not, but the attached should give you some insight into what others are doing:

https://www.unitedhealthcareonline.com/ccmc...Services_CD.pdf

[Guest Benny Guy]

I guess a lot depends on whether the plan is grandfathered or not, but the attached should give you some insight into what others are doing:

https://www.unitedhealthcareonline.com/ccmc...Services_CD.pdf

Thank you very much Gburns! Since this was preventative & a routine colonoscopy, with no previous polyps.... I think there's a good chance it should be covered as preventative.

[GMK]

What does the patient's own policy say about coverage for colonoscopies and polyp removal?

Some related reading (removing the polyp may change the billing):

http://bizmology.hoovers.com/2012/01/27/pp...about-the-bill/

http://preventingcolorectalcancer.org/taxonomy/term/30

[GBurns]

Benny Guy

Did you look at page 4 where it addresses a colonoscopy screening where polyps are found and removed?

Edit:

A polypectomy always caused a change in the billing codes. The only change caused by PPACCA is the prohibition against charging co-pays and coinsurance in non-grandfathered plans.

[Guest Benny Guy]

Benny Guy

Did you look at page 4 where it addresses a colonoscopy screening where polyps are found and removed?

Edit:

A polypectomy always caused a change in the billing codes. The only change caused by PPACCA is the prohibition against charging co-pays and coinsurance in non-grandfathered plans.

Yes, but right above that section in the "preventative section":

If a polyp is encountered during preventive screening colonoscopy, the colonoscopy,

removal of the polyp, and associated facility, lab and anesthesia fees done at the same

encounter are covered under the Preventive Care Services benefit.

[GMK]

Yes, but right above that section in the "preventative section":

Keep in mind that different policies will have different coverages, which in some cases will be better than required by law.

What does the patient's policy say?

[Guest matthew222]

I would still check your policy. I believe there are some grey areas under the PPACA preventive care umbrella that are left open to interpretation. The link GBurns provided is for UHC. If the plan in question is also insured through UHC it appears that it would be covered at no cost to the patient. If the plan in question is one of the 40 BCBS's, CIGNA, Aetna, etc., there may be a different interpretation.

[masteff]

Seems that it's a wide spread question: http://boston.cbslocal.com/2012/02/14/angr...ait-and-switch/

I'm totally confused by the concept that finding something during a "preventative" procedure makes it no longer preventative. Isn't the purpose of a preventative procedure to find something before it gets out of hand?

[Guest Benny Guy]

Yes, I will check the policy of course. Just wanted to know if it was even worth looking at it before I went through it, and also have a basis of what I'd be looking for. Thank you for the help everyone, great stuff.