Where preventive health care is concerned, a colonoscopy is one of the pricier screening tests, with a cost that often exceeds $1,000.
But under the health care overhaul, most health insurance plans have to cover the test for colorectal cancer without billing patients a dime, even if a polyp is found and removed.
Yet the way your doctor categorizes the test can make all the difference.
Save yourself some hassles by checking with your doctor before the colonoscopy to make sure the office will bill the insurer for the procedure as preventive screening rather than a diagnostic test, says Georgetown University's Katie Keith, who co-authored with the Kaiser Family Foundation and others a recent study about colonoscopy coverage under the Affordable Care Act's preventive coverage requirements. (Kaiser Health News is an editorially independent project of KFF.)
Under the law, health plans are required to pay for a range of preventive health services without any charge to patients. To qualify, the tests have to be on the recommended list of the U.S. Preventive Services Task Force, an independent group of medical experts. The only exception is for the diminishing number of health plans that have grandfathered status under the law.
But gray areas remain. Recent guidance from the federal government resolved some but not all of these.
Colorectal cancer screening is recommended beginning at age 50 for people at average risk. A colonoscopy is favored by many clinicians as the most effective way to identify polyps that could be or become cancerous.
During a colonoscopy, polyps are discovered about half the time, the study reported. Until the Department of Health and Human Services clarified the rules, some insurers charged patients a copayment if a polyp was found, judging that the test was then diagnostic rather than preventive. Medicare beneficiaries continue to face a copayment if a polyp is removed during a screening colonoscopy.
Challenging a colonoscopy copay after the procedure has been performed can be difficult, says Keith. "We talked to a consumer assistance program and they said they had a tough time winning on these issues."