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Is a colonoscopy covered under health insurance?

Keep in mind...
  • The AMA considers colonoscopies to be one of the most common preventive medicine procedures performed
  • Colonoscopies are performed to detect and treat both benign and malignant conditions of the colon
  • The average cost of a colonoscopy is $3,000 dollars

The American Medical Association considers colonoscopy to be “one of the most commonly used invasive medical procedures,” and promotes its use as essential for detecting a variety of intestinal diseases.

Instrumental in the diagnosis and prevention of colorectal cancer, colonoscopies have become increasingly employed by physicians of many specialties, even family doctors.

While many experts believe that diseases of the digestive tract can be attributed to diet, identifying and removing abnormal growths has become a widely accepted practice since the introduction of fiber optic technology in medicine.

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Can I get health insurance with a pre-existing condition?

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One of the most recent developments in colonoscopy is the ability to produce high-resolution images that allow for better magnification, which helps doctors identify very small lesions and polyps.

The use of sophisticated dyes help differentiate between normal and abnormal tissues, along with highly detailed pictures, making irregularities on the intestinal wall more noticeable to screeners.

Some modern endoscopes have accessories that capture dual images to produce a panoramic view of the colon lining.

These advances may have increased the detection rate of abnormal growths in intestinal tissue, but that could be considered a negative from an insurance coverage perspective.

Colonoscopy Coverage Tricky To Calculate

Important as screening may be for people over 50, full coverage by a health insurance policy for a colonoscopy may be more of an exception than a rule.

Coverage may be nearly complete under some health plans, particularly for patients with a family history of colorectal disease.

But even though most policies promote early detection of potential health threats, the fine print can sometimes renege on a policy’s promises.

A colonoscopic procedure used to be considered a preventive treatment, but now many health insurance policies cover preventive procedures at 100 percent with little or no co-pay amount.

In fact, the new healthcare reform law has mandated that insurance companies and Medicare pay 100 percent for their patient’s preventive services.

However, if polyps are discovered, a biopsy is then performed, and the procedure will no longer be considered preventative.

At that point, the coding for the procedure will differ and patients may have their claims denied, or be responsible for steep co-payments.

Often the policy’s deductible will apply, raising the out-of-pocket costs for patients who may have been under the impression that the procedure was covered.

Reclassifying a procedure isn’t the only way insurers skirt around the payment of claims filed against policies. If symptoms have been reported or detected, especially by a prior screening or a patient’s testimony, a colonoscopy can be considered a diagnostic test.

Diagnostic tests are not regarded as preventive care, and therefore may not be covered at the same rate as a preventive procedure would be.

What is the average cost of a colonoscopy?

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The average total cost for a colonoscopy, as estimated by Blue Cross and Blue Shield, is around $3000, but the price can vary widely depending on what is found during the procedure.

There will probably be a fee for every polyp found and for every biopsy performed, as well as facility charges and doctor fees.

Any action taken by the performing physician will have its own procedure code and reimbursement guidelines

The city of New York implemented a colonoscopy campaign in 2003 that expanded screening services to its residents with education and outreach programs.

The study has proven a 24 percent increase in the number of colonoscopies performed on New Yorkers over the age of 50. An initiative of the plan entailed lowering the cost and increasing access to screening in every community.

Many patients were able to undergo a colonoscopy for as little as $250, and some paid nothing at all as a result of the city’s disease prevention measures.

But for much of the rest of the country, the majority of colonoscopies will come at a higher cost to the patient after the claims have been filed.

What are the risks of a colonoscopy?

Although a colonoscopy is not a surgical procedure, there are risks and potential side effects associated with the process.

The most common side effects are reactions to sedatives that are administered during the procedure. According to one study, 1 in 500 patients required surgery after a colonoscopy to repair gastrointestinal perforations.

The Centers for Disease Control recommends that only patients over 50 should schedule regular colonoscopies.

At one time, women were advised to have regular mammograms to detect cancerous growths as early as possible. Recent studies, however, lead some healthcare professionals to advise against routine breast cancer testing.

Some believe the tests to be too harmful to be an effective diagnostic tool. Now some experts foresee a time when regularly scheduled mammography is all but abolished.

It may not be prudent to allow insurance coverage to be the deciding factor in a patient’s choice to undergo disease screening.

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