The Affordable Care Act and Colonoscopy

The Affordable Care Act and Colonoscopy

Under the Affordable Care Act, screening colonoscopies are now fully covered by Medicare and by many private insurers. Patients will still be responsible for co-insurance or some out-of-pocket costs, if the colonoscopy is a diagnostic, rather than screening procedure. Patients may also be responsible for costs related to anesthesia.

What is the difference between a screening or a diagnostic colonoscopy?

A screening colonoscopy is a procedure done for a patient who has no symptoms of colon cancer. A diagnostic colonoscopy is done when a patient has related symptoms or has a polyp removed during the procedure. A family history of polyps or colon cancer may also indicate a diagnostic colonoscopy with some commercial insurers.

Can a patient go in for a screening colonscopy but then have to pay for a diagnostic procedure?

Yes. Even if the patient has no symptoms, the procedure will be classified as a diagnostic colonoscopy if a polyp is found. The good news is if that occurs, the procedure may have prevented the patient from getting colon cancer.

What kinds of symptoms could cause a colonoscopy to be classified by an insurer as “diagnostic”?

It will vary depending on the health care plan, but could include hemorrhoids, changes in bowel habits, or rectal bleeding. If a physician uses a diagnosis of family history, some commercial payers may also process that claim as a diagnostic colonoscopy.

How much do patients typically have to pay for a diagnostic colonoscopy?

Medicare patients would be responsible for the standard 20 percent co-insurance. For patients with private insurance, out-of-pocket costs will vary depending on the plan.

Who should a patient call to determine how much of their colonoscopy will be covered?

Patients can contact their insurer or benefits administrator directly. However, staff members at Stop Colon Cancer Now centers are trained to verify benefits before a procedure is scheduled to ensure patients are aware of all potential costs before their colonoscopy.

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