Anesthesia, Colonoscopy, and Co-Pays

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There's a new update on colonoscopy coverage! Guidance from Health and Human Services (HHS) indicates that issuers cannot impose cost-sharing for anesthesia services performed in connection with preventive colonoscopies.

We'll break it down a little bit...

The Background

Since the implementation of the Affordable Care Act (ACA), there has been confusion about preventive colorectal cancer screening and costs. The ACA requires insurance companies to waive any cost-sharing (meaning you don't have to pay copays or coinsurance or meet your deductible) for a preventive (also called "screening") colonoscopy.

However, when individuals with private insurance have a precancerous polyp found and removed during the colonoscopy, the exam is often reclassified as a "therapeutic or diagnostic" procedure (vs. "preventive") and patients are often charged some amount (called cost-sharing.)

Patients with private insurance are often responsible for anesthesia and pathology costs -- which can be very costly. Medicare also has similar issues with coinsurance and out-of-pocket expenses when it comes to colonoscopies being reclassified from "preventive" to "diagnostic."

More about Medicare cost-sharing.

The Clarifications

When the procedure is reclassified, it creates a loophole (and confusion for patients who suddenly receive a bill in the mail.) Such confusion has led to HHS clarifying the coverage and answering this question:

If a colonoscopy is scheduled and performed as a preventive screening procedure for colorectal cancer (in line with the USPSTF recommendations), is it permissible for an insurance plan or issuer to impose cost-sharing with respect to anesthesia services performed in connection with the preventive colonoscopy?

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No. The plan or issuer may not impose cost-sharing with respect to anesthesia services performed in connection with the preventive colonoscopy if the attending provider determines that anesthesia would be medically appropriate for the individual.

Read more: Types of anesthetics for colonoscopy

Does this guidance "fix" the issue?

Well, not exactly. The HHS guidance clarifies part of the problem regarding cost-sharing -- the part that relates to the anesthesia cost. However, there are still costs that might be associated with the exam, like the additional facility doctors cost for pathology if a precancerous polyp is found during the exam.

While this guidance allows a partial fix and is great clarification, it doesn’t completely fix the problem. It is important to also note that the HHS clarification only has an impact on private insurance, this does not resolve any of the issues related to cost-sharing and preventive care for Medicare.

Read more: Anesthesia cost and colonoscopy

The Impact

The issue of cost-sharing for a screening colonoscopy is a big deal. Removing precancerous polyps during a colonoscopy is what prevents the disease.

This cost-sharing issue has resulted in many people choosing not to have the procedure for fear of unexpected out-of-pocket expenses. It's caused a financial burden on some who did undergo screening and had a precancerous polyp removed. Until this issue is fully resolved, it’s important you are aware of what costs you may be charged if you schedule a screening colonoscopy.

It is still incredibly important to be screened for colorectal cancer. If you are concerned about the cost or potential cost, discuss this with your health care biller and your insurer.

Get resources on low-cost screening options.

What Can We Do?

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This may seem daunting, but it's the power of our voices that will create change.

Fight Colorectal Cancer is helping lead legislation to reduce barriers for screening colonoscopies, like cost-sharing. Get involved in these efforts with us!

We make it easy. Sign up as an advocate right now and send an email (or social media message) to your representatives.

Ask them to co-sponsor the "Removing Barriers to Colorectal Cancer Screening Act" for the Medicare population. And then, ask for further clarification of private insurance cost-sharing.

More:

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2 thoughts on “Anesthesia, Colonoscopy, and Co-Pays

  1. Awesome information here. I know many people loo for exactly this kind of explanation when doing their pre-colonoscopy research.

  2. It looks like there’s more nuance to colonoscopies than I thought. The timing of a procedure can make it either “therapeutic” or “diagnostic”. I didn’t know that made a difference when it came to insurance.

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