Patients Waking Up To Major Colonoscopy Bill

Patients Waking Up To Major Colonoscopy Bill

Patients Waking Up To Major Colonoscopy Bill

The NYT article  – Waking Up to Major Colonoscopy Bills illustartes what our clients are increasingly running into – increased out of pocket expenses.

“Patients who undergo colonoscopy usually receive anesthesia of some sort in order to “sleep” through the procedure. But as one Long Island couple discovered recently, it can be a very expensive nap. Both husband and wife selected gastroenterologists who participated in their insurance plan to perform their cancer screenings. … And in both cases, the Gastroenterologists were assisted in the procedure by anesthesiologists who were not covered by the couple’s insurance. They billed the couple’s insurance at rates far higher than any plan would reimburse — two to four times as high, experts say.”

Patients can go for Colonoscopies either  in an outpatient medical office or in ambulatory hospital setting.   Gastrointerologists cannot bill for the anesthesia unless there is an employed licensed Anesthesiologist on staff.  The treating Physician cannot be the same person who administer/monitors the sedation. Generally speaking the Anesthesiologist in a hospital settings are separate entities and attempt to bill independently form the hospital charges. Now you can begin to see how patients are getting  added billing.

Furthermore, we are seeing increasing  out of network charges with Physicians dropping health plans in certain geographic areas as well as insurers shifting more of the costs burden.

The posting Out of Control Out of Network Charges points to examples such as – “a neurosurgeon charged $159,000 for an emergency procedure for which Medicare would have paid only $8,493.”  Another example: “ a consumer went to an in-network hospital for gallbladder surgery with a participating surgeon. The consumer was not informed that a non-participating anesthesiologist would be used, and was stuck with a $1,800 bill. Providers are not currently required to disclose before they provide services whether they are in-network.” The average out-of-network radiology bill was 33 times what Medicare pays, officials say.

Our clients get 3 bills with any procedure needing general anesthesia

1)   A bill from the hospital

2)  A bill from the surgeon

3)  A bill from anesthesia

Actually, the physician bill is typically the lowest cost of the bill .  On a $5,000 total bill the GI may only get 10%.  Sometimes the hospital and anesthesia charges are bundled into a single bill but many times they are not.  On most plans patients can negotiate with the hospital depending on pre-authorization the anesthesia bill and resubmit charges.  This is probably the most common appeal we perform on behalf of our clients.

Patient on a cost sharing plan with in-network deductibles may fair better  with outpatient office colonoscopies.  From an insurer costs perspective the charges in an office setting are typically $2,000-$2,500.  So why do it in the hospital? The procedure may require general anesthesia and financial incentives. Also, at times the procedure may be a loss to the provider.  For example, Pediatricians  will not perform Gardasil vaccination because the vaccine costs more than what the pediatrician will get reimbursed to give it.

The vast majority of providers make sure that  patients were in-network or arranged pre-payment plan prior to the procedure.  As with most non-HMO plans, however, the responsibility rests with patient to make sure everything is pre-authorized and in network is possible.