Is a colonoscopy really surgery?
February 23, 2012 9:43 AM Subscribe
I had an endoscopy and colonoscopy in December. I was put under twilight sedation during the procedure, and when it was over, I went home. Now my insurance company is claiming that this outpatient procedure counts as surgery, which has a copay of $150. Are they right?
I was never given a choice about whether they would sedate me. I assumed that since they were going in both ends in quick succession (all done within an hour or so) that it was necessary. I'm not even sure that I would have opted out of twilight sedation, but instead of being a free procedure, it's now a $150 outpatient surgery.
FWIW, I sent an email message to my insurance company (through their online messaging system) asking them why this is considered surgery, and this is their response: After reviewing your records, we are showing that based on your benefits, there is a $150 copayment for outpatient surgery. A colonoscopy is an outpatient procedure that requires anesthesia. Nothing about how anything requiring anesthesia counts as surgery, though I assume that's what I'm supposed to take from that.
Can I fight this? Am I out $150? Is this normal? My insurance is IBX, specifically KHPE. I realize that many people pay significantly more than $150 for this, but this is actually a pretty significant amount for me. Thanks in advance.
I was never given a choice about whether they would sedate me. I assumed that since they were going in both ends in quick succession (all done within an hour or so) that it was necessary. I'm not even sure that I would have opted out of twilight sedation, but instead of being a free procedure, it's now a $150 outpatient surgery.
FWIW, I sent an email message to my insurance company (through their online messaging system) asking them why this is considered surgery, and this is their response: After reviewing your records, we are showing that based on your benefits, there is a $150 copayment for outpatient surgery. A colonoscopy is an outpatient procedure that requires anesthesia. Nothing about how anything requiring anesthesia counts as surgery, though I assume that's what I'm supposed to take from that.
Can I fight this? Am I out $150? Is this normal? My insurance is IBX, specifically KHPE. I realize that many people pay significantly more than $150 for this, but this is actually a pretty significant amount for me. Thanks in advance.
Best answer: And endoscopy and colonoscopy is considered outpatient surgery because they are taking biopsies, doing anesthesia, and you probably signed a consent outlined this and if something needed to be repaired they would do it then and there (say a bleeding ulcer).
Your $150 out of pocket is always reflective of deductable, in or out network benefits and out of pocket fees. Nothing "free" kicks in unless you met all of those requirements.
So unfortuantely, yes it's normal. It's called the language not being clear to customers that they have to meet all requirements before insurance kicks in for the free stuff.
For the $150 payment, you usually have 90-120 days to pay. You can call the hospital/provider and set up monthly payments (usually lasting 6 mo) to spread them out. That's how I work things.
posted by stormpooper at 9:51 AM on February 23, 2012 [1 favorite]
Your $150 out of pocket is always reflective of deductable, in or out network benefits and out of pocket fees. Nothing "free" kicks in unless you met all of those requirements.
So unfortuantely, yes it's normal. It's called the language not being clear to customers that they have to meet all requirements before insurance kicks in for the free stuff.
For the $150 payment, you usually have 90-120 days to pay. You can call the hospital/provider and set up monthly payments (usually lasting 6 mo) to spread them out. That's how I work things.
posted by stormpooper at 9:51 AM on February 23, 2012 [1 favorite]
And note that usually there are 2 charges coming your way. Provider (person doing the procedure) and then the hospital charge (anesthesia, IVs, recovery time). So there may be two bills coming your way. Again, call the provider/hospital and spread those puppies out.
I'm still paying off fertility exam from September 2011 and that was like $200. They can deal.
posted by stormpooper at 9:53 AM on February 23, 2012
I'm still paying off fertility exam from September 2011 and that was like $200. They can deal.
posted by stormpooper at 9:53 AM on February 23, 2012
Review everything you signed prior to the procedure. See if there's any language that helps your case.
Spend more time on the phone with the insurance company- document every call. You may get someone to budge.
I suspect you had "surgery." But pressing on the insurance company can't hurt.
posted by Lesser Shrew at 9:54 AM on February 23, 2012
Spend more time on the phone with the insurance company- document every call. You may get someone to budge.
I suspect you had "surgery." But pressing on the insurance company can't hurt.
posted by Lesser Shrew at 9:54 AM on February 23, 2012
Response by poster: OK, I suspected that it was just the language that was not very clear. I will probably just pay this. It seems like the odds are slim-to-none that the insurance will budge. Very quick responses, everyone. Thank you!
posted by two lights above the sea at 9:56 AM on February 23, 2012
posted by two lights above the sea at 9:56 AM on February 23, 2012
Just curious why you assumed it would be free before--are you over 50 and thus this counts as a preventive health service? Is it possible that you had assumed it would be free because you think of colonoscopies in general as being "preventive care" even though in your case it was actually being used as treatment for a condition?
I would be surprised if the sedation has anything to do with it. It's much more likely that your insurance company looked at the claim and decided the colonoscopy + endoscopy together indicated that this was therapeutic (that is, to treat a problem) and thus requires a copayment rather than preventive. Or maybe the doc removed a polyp during the colonoscopy and that pushed the procedure from preventive to therapeutic (as been happening frequently these days, evidently).
I'd go back to your insurance contract and try to find where they define "surgical" to see if you can argue that this falls under a medical procedure and not a surgical one. It's probably not something your doctor can change but you might have some success moving it to a different, lower type of copayment.
posted by iminurmefi at 10:01 AM on February 23, 2012
I would be surprised if the sedation has anything to do with it. It's much more likely that your insurance company looked at the claim and decided the colonoscopy + endoscopy together indicated that this was therapeutic (that is, to treat a problem) and thus requires a copayment rather than preventive. Or maybe the doc removed a polyp during the colonoscopy and that pushed the procedure from preventive to therapeutic (as been happening frequently these days, evidently).
I'd go back to your insurance contract and try to find where they define "surgical" to see if you can argue that this falls under a medical procedure and not a surgical one. It's probably not something your doctor can change but you might have some success moving it to a different, lower type of copayment.
posted by iminurmefi at 10:01 AM on February 23, 2012
Is it possible that you had assumed it would be free because you think of colonoscopies in general as being "preventive care" even though in your case it was actually being used as treatment for a condition?
Nothing in what the OP said indicated the purpose of the colonoscopy.
posted by Tomorrowful at 10:34 AM on February 23, 2012
Nothing in what the OP said indicated the purpose of the colonoscopy.
posted by Tomorrowful at 10:34 AM on February 23, 2012
My endoscopy was a 30 buck co-pay same as a physician office visit. Calling a biopsy a surgery is a new one on me.
posted by bukvich at 10:42 AM on February 23, 2012
posted by bukvich at 10:42 AM on February 23, 2012
Heh, last year I got billed for surgery when I had a bit of earwax removed. No copay, either -- $250 applied to my deductible for <5 minutes fiddling. It seems that Cigna considers it surgery any time the doctor sticks an instrument in an orifice.
posted by jon1270 at 10:44 AM on February 23, 2012
posted by jon1270 at 10:44 AM on February 23, 2012
OK, I suspected that it was just the language that was not very clear. I will probably just pay this. It seems like the odds are slim-to-none that the insurance will budge. Very quick responses, everyone. Thank you!
You should call (not email) your insurance company before you pay. I paid a $250 co-pay for "outpatient surgery" a few weeks ago, but when I called the insurance company it turned out to be covered 100% (no co-pay!) under a special "colonoscopy benefit". It's worth the time to talk to someone about this, even if it turns out not to be covered.
posted by vorfeed at 10:50 AM on February 23, 2012
You should call (not email) your insurance company before you pay. I paid a $250 co-pay for "outpatient surgery" a few weeks ago, but when I called the insurance company it turned out to be covered 100% (no co-pay!) under a special "colonoscopy benefit". It's worth the time to talk to someone about this, even if it turns out not to be covered.
posted by vorfeed at 10:50 AM on February 23, 2012
Response by poster: Hey again, folks. I didn't mention that they did take biopsies and that this was not a preventative care colonoscopy/endoscopy. I am 27 years old with random IBS stuff. Feel free to look through my question history, it is rich with fart jokes and beanplating. Heh.
posted by two lights above the sea at 11:01 AM on February 23, 2012
posted by two lights above the sea at 11:01 AM on February 23, 2012
If the procedures were necessary for a larger course of treatment, they might be considered preventative, in which case your insurance company might wave the charge (mine does, but I don't know if all do). Give them a call and ask under what circumstances the endo/colonoscopy fees get waived. If your situation merits it, issue a challenge.
posted by Blazecock Pileon at 11:05 AM on February 23, 2012
posted by Blazecock Pileon at 11:05 AM on February 23, 2012
Part of the Obamacare law went into effect last year, requiring preventive testing to be covered with no co-pay. While a screening colonoscopy is essentially the same procedure as a therapeutic colonoscopy, the coding is different. A therapeutic colonoscopy would trigger a charge resulting in a co-pay if the poster's insurer required it. For a screening colonosco py no co-pay is permitted.
posted by citygirl at 12:17 PM on February 23, 2012
posted by citygirl at 12:17 PM on February 23, 2012
This thread is closed to new comments.
The wikipedia definition was helpful for me.
"As a general rule, a procedure is considered surgical when it involves cutting of a patient's tissues or closure of a previously sustained wound. Other procedures that do not necessarily fall under this rubric, such as angioplasty or endoscopy, may be considered surgery if they involve "common" surgical procedure or settings, such as use of a sterile environment, anesthesia, antiseptic conditions, typical surgical instruments, and suturing or stapling. All forms of surgery are considered invasive procedures; so-called "noninvasive surgery" usually refers to an excision that does not penetrate the structure being excised (e.g. laser ablation of the cornea) or to a radiosurgical procedure (e.g. irradiation of a tumor)."
posted by zug at 9:48 AM on February 23, 2012