Should I get a $$$ colonoscopy tomorrow or wait?
June 20, 2018 6:03 AM   Subscribe

I'm scheduled for a preventative colonoscopy tomorrow, but just found out that it's going to cost $800, so I'm looking for help making this decision. (I will also speak to a nurse about it, but I have no bowel symptoms at all, so it's not strictly a health/medical issue.)

Current guidelines suggest that people with a family history of colon cancer (such as myself) should get a first colonoscopy at age 40, or 10 years before the age that their family member was diagnosed. I am 40 now, and my relative was 65 when their cancer arose (after a lifetime of terrible bowel problems, which I do not have).

My doctor suggested I get a baseline colonoscopy, but didn't know(?) that my insurance would treat this as outpatient surgery, so it will cost me $800 (I double-checked this with the insurance yesterday). Once I turn 50, however, the colonoscopy would be free. The thing is that I currently have about $15,000 of credit card debt, that I've been attacking fairly aggressively in recent years, and I do not wish to add another $800 to it.

I am not sure what's the best way forward (or what questions to ask my care provider later today, prior to beginning the colonoscopy prep), and would appreciate any insight. I'm fully aware that there are payment plans, I'm just wondering what's the point of doing this now, when the guidelines don't advise it, and it's going to cost so much more. I'm in the US.
posted by missmarymackmackmack to Health & Fitness (19 answers total)
 
Can you doctor override the age 50 requirement in some way? I'd at least delay until I had explored all less-costly options. It's not an emergency and this is a significant cost.
posted by quince at 6:16 AM on June 20, 2018


Can you have it both ways and schedule it for six months to a year out and squirrel away a little cash at a time, assuming there is no level of urgency?
posted by A Terrible Llama at 6:27 AM on June 20, 2018 [5 favorites]


There are some alternatives to colonoscopy for screening. The downside is you’re supposed to have them every year. I’m not sure if they’re good alternatives with your family history though. You’d have to ask your doctor that. Info from the American Cancer Society here.

If I were you, I’d pay out of pocket for the peace of mind. Colon cancer has increased a lot in younger people, and colonoscopies, unlike most screening tests, are actually preventative.
posted by FencingGal at 6:53 AM on June 20, 2018 [2 favorites]


Would the insurance company approve it if you got an order from a doctor that was the result of a genetic consult (during which you would say "I have a family history" and they would say "gosh, current guidelines indicate this test, here's the order")?
posted by wenestvedt at 7:04 AM on June 20, 2018 [9 favorites]


I would find out from the insurance company (or maybe you already know) whether you'd have to pay so much because they believe the testing is not medically indicated or because you just have to pay a certain percentage of any testing/surgery. If it's the former, as wenestvedt says, your doctor's office may be able to help convince them it's a medically necessary procedure. The doctor may be coding or explaining it in a way right now that doesn't match what the insurance company needs to tick the correct box.
posted by lazuli at 7:11 AM on June 20, 2018 [6 favorites]


I would cancel this procedure and give yourself a little time to do more research. Then make a time to chat with your GI specialist and do some more research. Screening guidelines for cancer, speaking in broad terms, is an issue of some controversy in medicine right now. I'm not saying your shouldn't get a colonoscopy, I'm saying you have some time to think about this. Ask your doctor about getting a FIT test instead (stool sample) and share your predicament. You can also give yourself some time to see how this can be negotiated with insurance as mentioned above.
posted by latkes at 7:44 AM on June 20, 2018 [6 favorites]


Call your insurance company and try to negotiate. Call your state's insurance commission, which will be under the Attorney General's office; they may be able to help you appeal the decision. I would wait to have it and push for coverage. If nothing else, make sure it apples to your deductible. Some insurance companies will use end-of-the-year out-of-pocket expenses towards the next year's deductible, so you could have it in December (because nothing's as festive colonoscopy prep, right?)

40 is a somewhat arbitrary choice, so having it next January would be okay, if you end up not coming close to your deductible this year. And, you know, eat bran. Good luck.
posted by theora55 at 7:52 AM on June 20, 2018 [1 favorite]


Best answer: There are two issues at hand:
1. Coverage: will your insurance cover this at all, after your deductible is fulfilled, subject to normal copays for such a service?
2. Preventative care/deductible: will your insurance cover this, without being subject to hitting the deductible first, as the preventative care requirements of the ACA require for people over 50?

If I understand correctly, I think that your insurance is covering it at their normal outpatient surgery rates (#1), but not as preventative care (#2), and you're more than $800 from your deductible so they're not actually kicking in any money. Is that true?

Unfortunately, if that understanding is correct, I think you're SOL on getting a normal visit reclassified as preventative; to my knowledge those age restrictions are pretty much hard-coded and inflexible. A letter of medical necessity may affect #1 but not #2. Perhaps others have more to say on getting things classified as preventative, though.
posted by mosst at 8:56 AM on June 20, 2018


Yes, check with your doctor and have them re-send the referral. In your case, it's not elective--it's per family history and high risk diagnosis of your provider. So they may need to just code it differently. I'd also call the doctor's office and ask for their opinion. If you're asymptomatic and can't afford the procedure *tomorrow*, probably safe to delay a bit (though ten years may be a bit long, only your doctor/provider can make that call).
posted by stillmoving at 10:42 AM on June 20, 2018 [2 favorites]


Remember that the age ranges are somewhat arbitrary; nothing special happens on your 40th birthday. Remember also that your odds of having colon cancer are very low: overall incidence is about 1/10,000 for people 20-49 and 1 in 1000 for people 50-65. (Your odds are slightly higher than others your age because of your family history.) And because it is a slow-growing cancer, delaying the screening is unlikely to be harmful in the unlikely case that you do have something.

So definitely delay it while you speak to your provider and investigate other options. You can always go ahead with something in a month, a year, or a decade.
posted by Mr.Know-it-some at 10:45 AM on June 20, 2018 [3 favorites]


The lifetime risk of colon cancer in the average risk population is about 5% so it's by no means a rare cancer. A colonoscopy unlike some other types of cancer screening reduces mortality risk.
That said, postponing the procedure for a few months while you check out your funding options is likely not the end of the world.
I would definitely inquire if they are going to charge you extra for polyp removal - I'm not in the US but in my country a colonoscopy with polypectomy costs twice or three times as much.
I can't link on my phone but Uptodate has free patient information sheets online, check them out if you haven't already.
posted by M. at 11:31 AM on June 20, 2018 [1 favorite]


If I were you, I’d pay out of pocket for the peace of mind. Colon cancer has increased a lot in younger people, and colonoscopies, unlike most screening tests, are actually preventative.

Seconded. My mother was diagnosed with Stage IV colorectal cancer at 42 and died at 48. Despite a rather extreme level of dread and anxiety, I had my first screening at 31...and I already had polyps. They were removed then and there (both were benign), and my doc recommended that I have colonoscopies every 5 years rather than every decade. To me, $800 is awfully cheap for peace of mind. I don't think you necessarily need to have the procedure tomorrow, but I wouldn't wait 10 years.
posted by timetoevolve at 1:13 PM on June 20, 2018 [2 favorites]


Best answer: I work in a health-insurance-adjacent industry and I suspect mosst is right - this sounds like a case where the procedure isn't being considered a "preventive service" but rather just a regular covered service subject to the same deductible/coinsurance requirements that other visits/procedures would. If that's the case, then a letter of medical necessity from your doctor won't help, unfortunately.

Not sure if you did any comparison shopping, but the cost for colonoscopies can really vary, especially if you're talking about a physician practice associated with (or owned) by a hospital versus one where the GI does the procedure in-office or at a non-hospital-owned center. If it were me, I'd probably cancel the appointment for tomorrow (oh god, I'm sorry if you've already done the prep, that's the worst) and call around to get some price estimates from different GI practices. I would be unsurprised to hear pretty significant variations in cost. One thing you want to triple-check with any GI practice is whether there will be a separate hospital / facility bill for the colonoscopy - physician bills can be high but the separate facility bills (for using the room, basically) are the real killer in terms of cost.

If the issue is your deductible, you could also consider delaying for 6 months until after open enrollment through your work / the marketplace and seeing whether it would make financial sense to get on a plan with a lower deductible.

I'm sorry, this sucks. An $800 bill for what is essentially a preventive service (even if it doesn't meet the USPSTF criteria for preventive services that most insurers use to determine what is covered at no cost) SUCKS, especially if you're staring down a big credit card balance already.
posted by iminurmefi at 1:36 PM on June 20, 2018 [1 favorite]


I was deemed 'high risk' due to family history, like yourself, and (ahem) did the screening five years ago, and here five years later am scheduled to do it again. (This is twice the rate of once every ten years for others without family history of CRC.)

I read with interest a WSJ article pointing out that the American Cancer Society on May 30th of this year recommends now CRC screening to occur in healthy adults at the age of 45, no longer 50. Here's a link to the open-access journal article.

Speaking with a gastroenterologist recently, their official society has yet to come up with their recommendation, and good for you to make it a priority. The WSJ piece said only about 66% of Americans get screening, so there's a lot of preventative screening that could occur but does not. And symptoms for CRC don't appear until it's often too late.

As others have said, get another referral and have another conversation with your insurance - they should be good to have you screen earlier, and should cover the cost of this screening.
posted by scooterdog at 2:01 PM on June 20, 2018 [1 favorite]


Someone I know (blushes) 'mis-remembered' some symptoms on coaching from my (I mean their) doctor. This qualified me for a reduced cost investigation. This (coincidentally, ahem) followed the diagnosis of late stage colon cancer in the daughter of a friend.

Consider it an insurance premium. You don't want to die like my friend's daughter, trust me on that.
posted by GeeEmm at 3:20 PM on June 20, 2018 [1 favorite]


My husband’s 40 year old cousin with a family history of cancer is currently dying of colorectal cancer. It’s awful and he did not have any preventative screenings even though he should have. By the time he had bowel symptoms and went to his doctor he was terminal.

Don’t wait until you’re 50. See if your doctor can talk with the insurance and have it recoded. If not, start saving up and reschedule, but I recommend you don’t put this off for years.
posted by lydhre at 5:30 PM on June 20, 2018


First-line screening in many countries is via a Fecal Occult Blood test, which is easier and cheaper than the colonoscopy. Perhaps you could arrange to have that done first, and make a decision about colonoscopy based on that?
posted by Jabberwocky at 1:25 AM on June 21, 2018 [1 favorite]


Save your pennies, call the insurance company. get the screening.
The love of my life went last year for his just turned 50 screening, Stage 4 colon cancer, terminal 24-30 months
The only sign was what he thought was a minor hemorrhoid.

My opinion, others may differ.. and now my eyes are leaking again so I have to go get that under control before my meeting, it tends to upset people
posted by ReiFlinx at 6:55 AM on June 21, 2018 [1 favorite]


Response by poster: Thank you all so much for your helpful and kind answers. In my case, I believe mosst and iminurmefi hit the nail on the head, that the insurance was covering it "correctly", just not as much as I'd thought, and I hadn't used any of my deductible yet. Everyone was also right, though, to suggest that I ask about cheaper kinds of procedures or wait til open enrollment to rejigger my insurance (try to find a lower deductible, or save up and add funds to a Health Savings Account). Ultimately, I decided not to reschedule, mostly due to convenience reasons. I already had the whole house to myself for the prep, and I had someone who could pick me up (both of these are extremely rare in my living situation). I figured I'd spring for the "full" procedure this first time, then I could ask for something less invasive/expensive in the future, after this one came back normal (which it did!)

If anyone happens upon this post in the future, here are two blog posts I also found helpful (1,2), with relevant questions quoted below, in case the blog disappears.
---

* What all is covered? Doctor’s fee, anesthesiologist, lab fees, anything else?
* Will there be a facility fee? Does there have to be, or can it be done at another place without a facility fee?
* What kind of anesthesia are you planning to use? How much will it cost?
* Some places choose to pay only for “twilight” anesthesia, while others want full general anesthesia. Do I have a choice, and what’s the price difference?
* If there is a separate anesthesiologist, is that person part of my network (if you’re insured)?
* Will all lab tests be done at a participating lab?
* Do you require a pre-procedure consultation? How much will that cost? Can I skip that?
* How about the stuff you have to take to empty your system before the procedure? How much is that going to cost? is it covered by insurance?
* Take notes, and take names and phone numbers. If you need to question a bill later, it’ll be much easier.
posted by missmarymackmackmack at 9:51 AM on June 22, 2018 [2 favorites]


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