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 frightened when the bleeding continued for weeks.
The Chicago well being care marketing consultant contacted his doctor at Northwestern Drugs, who referred him for a diagnostic colonoscopy, a minimum of partly as a result of Contos, 45, has a household historical past of colon points.
“I work out a lot,” he mentioned. “But my partner said this isn’t normal. My primary care physician said, ‘Given your family history, 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 the USA greater than 15 million instances a yr. Charges of colorectal most cancers are on the rise, notably amongst youthful individuals.
The process, which can also be a really helpful screening for individuals 45 or older, entails analyzing the massive gut utilizing a tube with a video digital camera that may additionally acquire tissue samples.
It usually 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 line with Contos’ medical report, the gastroenterologist who carried out his colonoscopy described it as “not difficult.” He biopsied and eliminated small growths referred to as polyps from two spots and recognized giant inside 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 doubtless reason for 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 value.) 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 said, ‘I don’t understand this.’ Then I started to research the cost.”
He requested the hospital what it fees for a diagnostic colonoscopy and was informed he’d been despatched a value estimate via his on-line affected person portal previous to the process.
The estimate, which took his deductible of $3,200 into consideration, listed a complete value of $7,203, with an out-of-pocket invoice of $2,381. He requested Northwestern why the costs have been practically 3 times the estimate and why his out-of-pocket share was practically twice as excessive.
One huge purpose 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 removal.” 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 value.
After analyzing Contos’ invoice, Littenberg mentioned it’s commonplace for suppliers to invoice for 2 colonoscopies in the event that they take away two or extra polyps in numerous methods, due to the additional work. As on this case, hospitals usually use a modifier code that reduces the quantity charged for the second billed colonoscopy so that they cost just for the additional work, he added.
“How do you explain that in sensible terms that anyone could understand?” Littenberg mentioned.
Even with that discount, Littenberg mentioned, he thought Contos’ whole out-of-pocket value of $4,047 was “a lot, though not rare for large academic centers.”
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 value knowledge.
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 told Northwestern, ‘I’m not paying that, and I don’t care if you send me to collections,’” he mentioned. He filed appeals with the hospital and Aetna however was in the end informed the billing was appropriate.
The Decision
In an e-mail, Contos informed the billing division that its cost was “ridiculously high.” A consultant responded that Northwestern’s pricing is according to 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 accurately” 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 completely 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 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 value web site and an insurer’s cost-estimator web site, each required by federal value transparency guidelines.
Sufferers can also lookup a good-faith estimate of the money value, which could be decrease than the worth for sufferers utilizing insurance coverage to pay for a process. As well as, they will examine costs via web sites resembling Turquoise Well being and Honest Well being, which draw from federal value transparency knowledge or claims knowledge from insurers.
Nonetheless, the precise value might be larger than the estimate if the colonoscopy finds a number of polyps that must be eliminated and biopsied, which happens in a minimum of 40% of all colonoscopies, Littenberg mentioned. Sufferers ought to ask whether or not the worth consists of these probably further companies. 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 have to be a medical billing expert to know what you’re going to pay.”
Invoice of the Month is a crowdsourced investigation by KFF Well being Information and The Washington Put up’s Nicely+Being that dissects and explains medical payments. Since 2018, this collection 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 might have a complicated or outrageous medical invoice you need to share? Inform us about it!
