Same Colonoscopy, Different Facilities, Wildly Different Costs
More than 16 million colonoscopies are performed in the United States each year. A common gastrointestinal procedure, colonoscopies are routinely performed as a screening for cancer, surveillance and as a diagnostic to evaluate symptoms. A colonoscopy is also one of the most frequently performed procedures in ambulatory surgery centers (ASC).
In this Audit Spotlight, we focus on routine screening colonoscopy services and the extreme differences in facility charges for this test.
How Much Does a Routine Colonoscopy Cost?
The differences in the cost for a routine screening colonoscopy procedure can be attributed to several factors:
- Location and facility type — whether the colonoscopy is performed in an ASC, hospital outpatient department, a physician’s office or, less seldom, in a hospital inpatient setting.
- Billing details — applicable CPT/HCPCS codes, modifiers, diagnosis codes and other information reported and billed on the claim.
- Insurance coverage — whether the patient is insured, uninsured or self-pay, as well as the type of insurance coverage they have.
- Health plan provisions — specific plan language and coverage details related to screening and diagnostic tests and procedures.
There will be a bill and related charge for the facility component and a bill and related charge for the professional component (practitioner performing the colonoscopy). There may also be additional professional charges billed by an anesthesia provider or a pathologist if a biopsy is taken, as well as a cost for the colonoscopy procedure preparation kit.
Federal Law
The Affordable Care Act requires that both Medicare and private insurers cover the costs of preventive colorectal cancer screening tests, as these tests are recommended by the U.S. Preventive Services Task Force. The law specifies that there should be no out-of-pocket costs for patients, such as copayments or deductibles, for these preventive screening tests.
Colonoscopy Charges: ASCs vs. Hospitals
Outlined below are claim examples detailing where colonoscopy services are performed, the associated colonoscopy CPT code/modifier, facility billed charge, hospital reported cost and ClaimDOC’s corresponding pricing.
Takeaways
Generally, charges for a colonoscopy procedure performed in an ASC facility can be significantly less than when performed in a hospital outpatient department. As noted in the above claim examples, the difference in charges are extreme not only among ASCs but also among hospital outpatient departments for the exact same procedure.
Healthcare policies are complex, often making it difficult to understand the full extent of a member’s coverage and benefits. Prior to routine colonoscopy services being performed, consider options of where to have the procedure and obtain a fee estimate of the cost.
Inquiries and communications with health plans and providers can assist in determining the financial liability for preventive or diagnostic colonoscopy procedures. Ask questions related to applicable age limits for the test, frequency parameters, coverage for pathology services, anesthesia services, if preparation kits are included in the plan, if there are partnerships with selected providers to obtain discounts, and other issues or concerns.
Being informed in advance of an elective procedure can help minimize the potential for surprise billing and unexpected costs.
Background
Our goal at ClaimDOC is to use benchmark charges and costs nationally to negotiate fair and ethical payments. Employers turn to us to establish fair reimbursement rates for their plans, allowing them to save money and provide richer benefits to their employees — a win-win for everyone.
ClaimDOC’s comprehensive line-by-line auditing of claims uncovers errors that basic claim repricing and auto-adjudication fail to catch, leading to greater savings for health plans and plan members. Our audit team analyzes all types of healthcare claims for a variety of potential concerns, including excessive usual and customary charges, duplication of claims, correct coding edits, unbundling of services, misuse of modifiers and numerous others. Our claims review is not intended to impact care decisions or medical practice.