Cost of a Colonoscopy With and Without Insurance

Coverage for Colonoscopy and Stool-Based Tests
  Commercial Insurance Medicare
Diagnostic Colonoscopy No full coverage No full coverage
Screening Colonoscopy Colonoscopy, bowel prep, sedation, lab work, and hospital or ambulatory surgery center Colonoscopy and sedation with no polyp findings; 85% coverage for polyp removal
Stool-Based Tests Stool-based test, colonoscopy, and polyp removal Stool-based test and colonoscopy 

Colonoscopies Under Age 45

Having a colonoscopy done with the approval of your health insurance provider depends mainly on your medical history. People younger than 45 might need to receive a colonoscopy if they have risk factors like:

  • A family history of colon cancer or polyps
  • A personal history of colon cancer or polyps
  • A personal history of inflammatory bowel disease
  • A personal history of radiation to the abdomen or pelvic area to treat cancer

For example, Brett C., a management consultant in Atlanta, told Health that he had his first colonoscopy at age 36. Brett started preventative screenings early because both of his parents were diagnosed with colon cancer and died within three months of each other. Subsequent screenings for both Brett and his brothers found precancerous polyps.

Your medical history will decide whether you need a colon screening before age 45 and if your insurance will fully cover it. Also, advocating for your health and having a trusted healthcare provider is crucial. You may need to “recruit [a gastroenterologist] to assist you in writing a letter of medical necessity,” Christin Sonneborn, a patient navigator at Colorectal Cancer Alliance, told Health.

Sometimes, there may be extra fees related to getting a colonoscopy. For example, a person may have something to pay if they have to have a colonoscopy after a positive stool-based test. Here are a few other reasons you might get an unexpected bill for your screening colonoscopy and what you can do to avoid surprise charges.

Out-of-Network Providers

Be aware of coverage for all healthcare providers involved in the colonoscopy. In other words, it’s not just the gastroenterologist who gets paid. You may end up receiving bills from:

  • The provider completing the colonoscopy
  • The location where the colonoscopy was completed
  • The anesthesia care team
  • The pathology lab, for cases of polyp removal or biopsies

“Always ask ahead of time about the [healthcare providers] who will participate in your procedure and request that they be in-network. If you aren’t given the choice of using an in-network anesthesiologist, this is through no fault of your own and can be appealed with your insurance,” said Sonneborn.

Bowel Prep Kit

You may be responsible for paying for your bowel prep kit and other services. Obtain the healthcare provider’s current procedural terminology (CPT) code for your colonoscopy to get accurate pricing and avoid unexpected costs. 

Questions that you should ask a health insurance carrier before your colonoscopy include:

  • Are there any out-of-pocket costs for the CPT code used by the healthcare provider?
  • Is the anesthesiologist being used in the network?
  • Will I save money by scheduling the procedure at an ambulatory surgery center (ASC) versus a hospital outpatient department (HOPD)?

Complications

The insurer might initially approve coverage for a colonoscopy, then reverse their decision if screening detects precancerous polyps. The policy may vary with different payers.

Brett, who had private insurance, shared that his “biggest surprise bill was when my [healthcare provider] punctured my colon during my colonoscopy, and I spent three days in the hospital. I had to pay for a portion of those costs, too. Keep in mind that I worked for a Fortune 100 company, and I’d selected the best health insurance options available.”

The Centers for Medicare & Medicaid Services (CMS) has indicated that removing polyps is part of the colonoscopy process and should not incur shared costs. However, the screening colonoscopy guidelines differ if you are a Medicare beneficiary. The screening colonoscopy becomes a diagnostic colonoscopy, and you will be responsible for a copay if the healthcare provider finds a polyp.

You can access the Procedure Price Lookup Tool to compare payments and copays for colonoscopies and other medical procedures performed in ASCs and Hospital Outpatient Departments (HOPDs).

“Recent Medicare guidelines encourage coding and billing of colonoscopies based on intent, which means that if your colonoscopy was scheduled as a preventive screening, it should remain as such, whether it finds and removes polyps or not,” said Sonneborn.

This can be frustrating, as “no one goes into a routine screening expecting bad news. If a patient is being responsible and following through with preventative screening, they shouldn’t be penalized with a surprise bill because polyps were found,” added Sonneborn.

Colon cancer screening is equally important for people without insurance. You can consult the Healthcare Bluebook to compare colonoscopy costs in their area.

There are options for getting a free or low-cost colonoscopy, including:

Knowing your medical status can be lifesaving. Screenings like a colonoscopy may not seem a priority if you are juggling daily finances and are in excellent health. Still, the overall cost of cancer treatment might make you think twice about delaying screening.

A colonoscopy can detect colorectal cancer early, which can help maximize your survival chances if you have the disease. Experts recommend that most people start colorectal cancer screening at 45. High-risk groups might need to begin screening even earlier than that.

Make sure that all healthcare providers, including anesthesiologists, are in-network. Advocating for yourself, asking questions as necessary, and being aware of your options, whether you are insured or not, can help minimize your colonoscopy costs.

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