Insurance and Cologuard

June 21, 2020 3:23 PM

Because of no elective surgeries allowed during the covid lock-down, I chose to get a Cologuard screening vs a colonoscopy. The doctor told me my insurance would cover it 100%. He was wrong.

My insurance company considers Cologuard to be diagnostic, not screening. My doctor submitted the Cologuard bill to my insurance company, but my insurance company declined to pay pending my doctor submitting my medical record to prove that it was diagnostic. (It was not.) Even if it were diagnostic, my insurance company would only pay 80%. As it stands, I will have to pay the entire $645 amount.

Unfortunately, the Cologuard result was positive. So now I will need a colonoscopy. My insurance company pays 100% for screening colonoscopies. But now that my insurance company knows I had a Cologuard test, will they consider the colonoscopy to be diagnostic vs screening (even though I was the one who paid for the Cologuard test, not them)? If so, I will have to pay 20% of the colonoscopy - which in the end will mean I had to pay 20% of the colonoscopy plus the entire amount of the Cologuard! If I had just had the colonoscopy and skipped Cologuard, insurance would for sure have covered 100% of the procedure.

Anyone else have any experience with this scenario?

Thanks!!

posted by SageTrail to Health & Fitness (4 answers total)

Best answer: My first colonoscopy had polyps, so they scheduled me to come back in 5 years (which was just recently). As best I was able to determine, my shitty insurance with Providence would have handled the recent colonoscopy as follows: if nothing was found, I would pay nothing (or $50 co-pay or whatever). However, if anything was found, then I would pay the full price. (Figuring out the full price was another labor of Hercules: it was "probably" somewhere between $3000 and $10,000, and apparently impossible to say with any greater certainty than that, despite the endless stream of people getting colonoscopies at that facility.)

I chose to go to a self-pay-only place that gave me a flat price of about $1000 (which, I'm sure, was the result that Providence actually intended).

The colonoscopy itself turned up nothing, but I am 100% sure that if I'd gone to the randomly expensive place affiliated with Providence, they would have found something and I'd still be fighting over the bill.
posted by spacewrench at 4:28 PM on June 21, 2020 [1 favorite]

Best answer: Two years ago, my doctor prescribed a Cologuard test for me. She did warn me that my insurance might not cover it.

The insurance did not cover it. However, Cologuard also provided resources for me to appeal this, to both the insurance company and to my state's insurance commissioner -- they literally provided pre-filled letters and forms along with the invoice. I then carried through on all that, through multiple appeal cycles. I also harangued my company HR directly that they should be covering this on their employees (it was a big tech company, flush with earnings). Basically I spent a year on this stupid thing.

After the last appeal was declined, I gave up and resigned myself to paying for it. But then Cologuard never sent me another bill. I think they gave up too :)
posted by intermod at 8:10 PM on June 21, 2020 [3 favorites]

Response by poster: LOL, intermod, at "they gave up too". The answers here were very helpful in that they show me the confusion and hassle is "normal". Thank you.
posted by SageTrail at 2:03 PM on June 22, 2020

Response by poster: Update: My doctor never did submit my medical record to my insurance company, despite my calling my doctor multiple times, and even writing them a letter, to try to find out why they hadn't submitted it. They never responded to my inquiries. Finally, 5 months later, I went to my doctor's office, asked the receptionist for a copy of my medical record, she printed it out and handed it to me, I submitted it myself to my insurance company, and within a few weeks my insurance company reimbursed me 80% of the $645. Needless to say, I will never go to that doctor again!
posted by SageTrail at 3:13 PM on January 16, 2021