Wellness

[Lipstickdiva]

I'm at the age, actually I was at that age last year, when I need the "dreaded" (at least to me) colonoscopy.  My doctor put the order in and I went for the consult yesterday and was scheduled for the procedure.

Imagine my surprise when I found out this wouldn't be covered by insurance.  I got out our insurance coverage guide and although this procedure wasn't mentioned, it said all screening tests are excluded from coverage with the exception of a mammogram, routine chest x-ray, complete blood panel and a few other things.

I contacted my insurance company this morning to make sure I understood and sure enough, the rep. said that preventive endoscopic procedures are not covered.  She said if they find something during the screening procedure, it then becomes a diagonstic procedure and would then be covered at 80% after I meet my deductible.  Otherwise, I am self-pay.

The rep indicated that because of the year the company's insurance policy went into effect, the company is grandfathered in and not required to follow ACA guidelines which mandates that preventive screening tests be covered 100%.  

I am going to pay for this out of my pocket and fingers crossed this doesn't become diagnostic because they find something.  I'd rather self pay then have that happen.  

But just a heads up to make sure you know your coverage.  What prompted all of this was someone actually showed up for the test and was told it wasn't covered.  He left without having the procedure after going through that prep!   

[icezeus]

I am speechless not only for you, but also for the poor person who had to do the horrible prep only to be told that the procedure would not be covered.

[Peaches McPhee]

Thanks for the heads-up.  Always good to remember to never assume anything.  

[Krimpette]

I'm surprised that the doctor's office would not have known in advance that the procedure would not be covered.  SMH.

[Sunnycorle]

Mine does.  What insurance do you have?

[2blonde]

@Lipstickdiva   That's awful.  It's bad enough to have to do it, but to pay for it as well?  Seems like a lot of people won't get screened and may actually get the disease, which will cost the insurance company much more!

I think the procedure runs into the thousands of dollars, doesn't it?

[Suzeecat]

What a racket!  I'm of the age where I've had a few of these procedures under my belt.  My first one, the dr. said she found a few polyps, took care of them, no problem.  Second one five yrs later was clear.  The third one, when I scheduled, I was asked if I ever had polyps to which I honestly said yes.  Then I was told oops, because you have a "history" the procedure is coded differently and insurance doesn't cover that particular code.  I told her that BCBS told me differently and was forced to leave a credit card anyway "just in case" there was a charge.  That third procedure revealed no polyps or anything unusual and it turns out BCBS did pay for it all but after this if I am asked if I've every had polyps I will say no.  Live and learn!

[DrakesMomma]

I've worked in medical billing for 21 years.  I applaud you for looking into this before your procedure.  Although you consider yourself as "self-pay" make sure the facility and/or providers bill your insurance company.  They could be contracted with your insurance and may need to take a contractual adjustment.  That could reduce your out-of-pocket. 

Sending good thoughts for a smooth, quick procedure and a good pathology report.  

[tobes]

I understand doctors report finding a polyp as a means of making the procedure diagnostic if your ins ompany does not pay for preventative.  i believe most ins companies payfor this as preventative.  My medicare policy pays in full for this service, but only if you have it done at a clinic.  If you have it done in a hospital setting it pays 80 percent.  Go figure.  Does your ins pay in full if you are of a certain age?

[Lipstickdiva]

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@Krimpette wrote:

I'm surprised that the doctor's office would not have known in advance that the procedure would not be covered.  SMH.

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I contacted them after I found out and they said I was on the list to call because they found out that my insurance wouldn't pay for it when they ran it for pre-approval.