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 turned more and more apprehensive when the bleeding continued for weeks.
The Chicago well being care advisor 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 loads,” he mentioned. “However my accomplice mentioned this isn’t regular. My main 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 instances a 12 months. Charges of colorectal most cancers are on the rise, notably amongst youthful individuals.
The process, which can also be a beneficial 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 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 just lately chaired the reimbursement committee of the American Society of Gastrointestinal Endoscopy.
Based on Contos’ medical file, 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 inner 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 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 offended when he obtained his itemized invoice. “I mentioned, ‘I don’t perceive this.’ Then I began to analysis the fee.”
He requested the hospital what it costs for a diagnostic colonoscopy and was instructed 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 costs had been practically thrice the estimate and why his out-of-pocket share was practically twice as excessive.
One large 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 removing.” Aetna’s negotiated member price 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 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 wise phrases that anybody may perceive?” Littenberg mentioned.
Even with that discount, Littenberg mentioned, he thought Contos’ whole out-of-pocket value of $4,047 was “loads, although not uncommon for giant tutorial facilities.”
Contos’ insurance coverage paperwork present Aetna’s negotiated price for his colonoscopy at Northwestern was greater than twice the insurer’s median negotiated price for a similar process at different Chicago-area hospitals, based on 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 truly being billed for 2 procedures, which Contos discovered bewildering.
“I instructed Northwestern, ‘I’m not paying that, and I don’t care when you ship me to collections,’” he mentioned. 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 consistent with 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 mentioned 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 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 research discovered that ambulatory surgical procedure facilities billed insurers a median 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 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 will be decrease than the worth for sufferers utilizing insurance coverage to pay for a process. As well as, they will verify costs by way of web sites corresponding to Turquoise Well being and Honest Well being, which draw from federal worth transparency information or claims information from insurers.
Nonetheless, the precise value might be increased than the estimate if the colonoscopy finds a number of polyps that should be eliminated and biopsied, which happens in at the very least 40% of all colonoscopies, Littenberg mentioned. Sufferers ought to ask whether or not the worth consists of these probably further providers. In spite of everything, the purpose of a diagnostic colonoscopy is to search out and, if crucial, deal with lesions that would trigger issues — whatever the quantity discovered.
All of it must be simpler for sufferers, Xiao mentioned: “You shouldn’t must 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 Submit’s Properly+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 got a complicated or outrageous medical invoice you need to share? Inform us about it!
