The Affordable Care Act requires recommended preventative services, such as colonoscopies, be covered at no cost to the patient. However, strict guidelines are used by insurance companies to determine whether a colonoscopy is categorized as preventative or diagnostic, which can impact your potential out of pocket cost.
Before your colonoscopy we want to help you plan for the potential costs. Much of this starts with understanding the reason for your colonoscopy. Is it preventive, such as a routine colonoscopy, or it diagnostic for evaluation reasons or treat existing condition?
Is My Colonoscopy Preventative or Diagnostic: What You Need to Know
Preventative Colonoscopy Screening: Patient is asymptomatic (no present gastrointestinal symptoms), is age 50 or older, and has no personal history of gastrointestinal disease, colon polyps and/or cancer. A colonoscopy has not been performed within the past ten years. This is usually a routine screening colonoscopy and covered by most insurance plans
Surveillance / High-Risk Colonoscopy: Patient is asymptomatic (no present gastrointestinal symptoms) but has a personal history of gastrointestinal disease (such as diverticulitis, Crohn’s disease or ulcerative colitis), colon polyps and/or cancer. Shorter intervals between colonoscopies are recommended for these patients (usually every 2-5 years). Some insurance carriers consider surveillance / high-risk colonoscopies to be preventative, while others consider them to be diagnostic. This is an important note and something to ask your insurance provider.
Diagnostic / Therapeutic Colonoscopy: A colonoscopy is performed to evaluate or treat gastrointestinal symptoms, colon polyps or gastrointestinal disease.
Before your procedure you should know your colonoscopy category. You should obtain the pre-procedure diagnosis code (meaning the reason for the procedure) from the scheduler or medical assistant. With this information you can contact your insurance carrier to determine:
Is a colonoscopy procedure with this diagnosis (provided by scheduler or medical assistant) covered under my policy?
If so, will the diagnosis be processed as preventative or diagnostic? If my procedure will be diagnostic, will the allowable amount be allocated to my deductible? Once the deductible is met, will any additional amounts be allocated to coinsurance? Please note: If your procedure will be performed at one of our endoscopy center locations be sure to tell your insurance carrier that the procedure will NOT be performed in an outpatient setting.
If the procedure will be considered as diagnostic and the allowable amount will be allocated to your deductible, please contact the CRS Business Office at (804) 249-2465 for an estimate of what you can expect to pay.
The physicians at CRS cannot change the primary diagnosis for the sole purpose of coverage determination. The diagnosis must be an accurate reflection of your medical history and the information you provide during our pre-procedure assessment. This is a regulatory requirement imposed by both government agencies and insurance companies with whom we are under contract.