Colonoscopy and Insurance Benefits

The Affordable Care Act requires that insurance policies cover certain preventative services, such as colonoscopies, at no cost to the patient.  However, the insurance industry has established strict guidelines for what defines a screening/preventative service.  The guidelines may exclude patients with current symptoms, history of gastrointestinal disease, or a personal or family history of colon polyps or colon cancer from meeting the definition of a screening/preventative colonoscopy.  Please understand that your primary care provider may refer you for a “screening” colonoscopy, however, you may not meet the guidelines for a screening/preventative colonoscopy benefit, according to your insurance policy guidelines. 

Arizona Digestive Institute defines colonoscopies in three categories:

Diagnostic/Therapeutic Colonoscopy-patient would have gastrointestinal symptoms such as, but not limited to, diarrhea, constipation, rectal bleeding, abdominal pain, anemia, personal history of gastrointestinal disease, or abnormal test results (ie: ultrasound or CT scan).The procedure is usually subject to copay, coinsurance and/or deductible.

Surveillance/High Risk Colonoscopy-patient would not have any current symptoms or history of gastrointestinal disease. However, the patient has a personal or family history of colon polyps and/or colon cancer. Patients in this category usually have colonoscopies every 2-5 years. The procedure may be subject to copay, coinsurance and/or deductible.

Screening/Preventative/Average Risk Colonoscopy-patient has no symptoms, is 50 years old or older, has no history of gastrointestinal disease, and no personal or family history of colon polyps and/or cancer. Patients in this category usually have colonoscopies every 10 years. If these guidelines are met, the procedure may be covered at 100% depending on your insurance policy benefits.

Frequently Asked Questions

Q.  Can the provider change, add or delete diagnosis so that my colonoscopy can be paid as a screening/preventative procedure?

A.  No.  Your medical record is a legal document and any history or symptoms documented in your record cannot be altered to allow for better insurance coverage.

 

Q.  What if my insurance tells me that ADI can change, add or delete a CPT code or diagnosis code and “just file it as a screening”?

A.  This is a fairly common question that we hear from our patients.  Please document the date, representative’s name, phone number and a call reference number for the call to your insurance company.  Then contact the Business Office Manager at ADI.  We will contact our provider representative for your insurance company and request re-training for the individual you spoke to, as the information you received is incorrect.  If your procedure does not meet the guidelines for a screening/preventative colonoscopy, we cannot re-code and file a claim to obtain a higher benefit for you.

 

Q.  How will I know exactly what my costs will be?

A.  We cannot quote your exact costs or benefits prior to your procedure.  We use procedure codes and diagnosis codes to submit claims to insurance.  The procedure code will vary depending on what is done during your colonoscopy.   For example; a colonoscopy without polyp removal is a different procedure code than a colonoscopy with polyp removal.  We can estimate your costs for the physician fees based on our contracted rates with your insurance company.  However, this is never a guarantee of actual costs as your insurance benefits will be determined by your insurance policy after a claim is submitted by ADI.