Tom Kontos is an avid runner. When I started experiencing rectal bleeding in March, I thought it could be caused by exercise and tried to ignore it. But as the bleeding continued for several weeks, he became increasingly anxious.
A medical consultant in Chicago contacted a doctor at Northwestern Medical School who referred him for a colonoscopy. That’s at least in part because Kontos, 45, has a family history of colon problems.
“I exercise a lot,” he said. “But my partner said this is not normal. My doctor said, ‘Given your family history, let’s admit you.'”
Northwestern Memorial Hospital required him to pay a $1,000 copay upfront, and he underwent surgery in June.
Then the bill came.
medical treatment
More than 15 million colonoscopies are performed annually in the United States. The incidence of colorectal cancer is increasing, especially among young people.
The procedure is also a recommended screening for people over 45 and involves examining the colon using a tube equipped with a video camera that can also collect tissue samples.
Dr. Glenn Rittenberg, who recently served as chairman of the reimbursement committee for the American Society of Gastrointestinal Endoscopy, said the exam typically takes less than an hour, and an additional hour to review the patient’s medical history. The patient’s time will be spent listening to him, administering anesthesia, and monitoring his recovery.
According to Kontos’ medical records, the gastroenterologist who performed the colonoscopy said it was “not difficult.” He performed biopsies to remove two small tumors called polyps and identified large internal hemorrhoids with swollen veins.
The biopsy sample was sent to pathology for testing and was found to be pre-cancerous. However, the gastroenterologist reported that he found no evidence of cancer and, after reviewing the pathology report, concluded that the cause of the bleeding was likely hemorrhoids.
final invoice
The hospital charged a total of $19,206 for the surgery, including doctor’s fees. The insurance company negotiated the price down to $5,816 and paid $1,979, leaving the patient’s share of $4,047. (It’s not clear why the payment was slightly more than the negotiated price.) After Contos paid $1,000 upfront and another $1,381 immediately after the surgery, the hospital still owed $1,666. He said there is.
Billing issues: Colonoscopies to find polyps are getting more expensive
Kontos was shocked and angry when she received the itemized bill. “I said, ‘I don’t understand this.’ Then I started looking at the costs.”
He asked the hospital how much he would pay for a colonoscopy and was told that a cost estimate would be sent to him through an online patient portal before the procedure.
Taking into account his $3,200 deductible, the estimate listed a total cost of $7,203 and out-of-pocket costs of $2,381. He asked Northwestern why the cost was nearly three times the estimate and the out-of-pocket cost nearly double.
One of the big reasons was revealed in an Explanation of Benefits (EOB) statement from Kontos’ insurance company, Aetna. Northwestern was charging $5,466 each for two colonoscopies. The gastroenterologist then had two fees: $1,535 and $1,291.
The first procedure was listed as “colonoscopy and biopsy,” and the second procedure was listed as “colonoscopy with lesion removal.” Aetna’s negotiated membership rates reduced the first $5,466 hospital stay to $3,425 and the second surgery to $1,787, a $1,638 reduction.
Neither the bill nor the EOB explains why the second step is listed at a discounted price.
After reviewing Mr. Kontos’ bill, Mr. Rittenberg said that the provider charges for two colonoscopies because of the extra work that occurs when two or more polyps are removed using different methods. He said it is standard to do so. He added that, as in this case, hospitals typically use modification codes that reduce the bill for the second colonoscopy, so you end up billing only for the additional work.
“How do you explain that in sensible terms that everyone can understand?” Rittenberg said.
Even with that reduction in mind, Rittenberg said he believes Contos’ total out-of-pocket cost of $4,047 is “high, although not unusual for a large academic center.”
Aetna’s negotiated rates for colonoscopies at Northwestern were more than twice the median rate negotiated by insurers for the same procedures at other Chicago-area hospitals, according to Contos insurance documents. , said Forrest Hsiao, director of quantitative research at data collection company Turquoise Health. Medical pricing data.
During an exchange with representatives from Northwestern and Aetna, Kontos asked why he was charged with two colonoscopies. Northwestern’s representatives said they were not actually charged for the two procedures because of the qualification code, which Contos found confusing.
“I told Northwestern, ‘I’m not paying for that, you can send it to collections,'” he said. He disputed the charges with the hospital and Aetna, but was ultimately told the charges were correct.
resolution
In an email, Kontos told the billing department that the charges were “ridiculously high.” The representative responded that Northwestern’s pricing is in line with other academic medical centers in Chicago and is “non-negotiable,” and that his account would be turned over to a collection agency.
In a written statement to KFF Health News, CVS Health spokesperson Phillip Brand said Kontos’ benefits were “accurately paid” by Aetna and declined further comment. (CVS Health owns Aetna.)
Northwestern did not respond to multiple requests for comment.
Kontos said she wrote a letter to her doctor saying that she was disappointed in her resignation and was planning to leave Northwestern University altogether, citing the health care system’s high rates.
He said he still suffers from periodic symptoms, which he uses over-the-counter Formulation H to alleviate. At CVS, a 1 oz tube of ointment costs $10.99.
Take-out
Rittenberg said that for a lower cost colonoscopy, patients should consider going to an independent endoscopy center or outpatient surgery center that is not affiliated with a hospital. A 2023 study found that outpatient surgery centers charged insurance companies an average of about $1,030 for a colonoscopy with biopsy or polyp removal, compared to $1,760 at hospitals.
this month’s bill
See more series
To find out how much a diagnostic colonoscopy will cost, patients can refer to their hospital’s pricing website and their insurance company’s cost estimating website. Both of these websites are required by federal price transparency regulations.
Patients can also look up honest estimates of cash prices. This can be lower than the price if the patient uses insurance to pay for the surgery. You can also check prices through websites like Turquoise Health and Fair Health. These websites are based on federal price transparency data and claims data from insurance companies.
Still, the actual cost may be higher than estimated if the colonoscopy finds one or more polyps that require removal and biopsy, which occurs in at least 40% of all colonoscopies. Rittenberg said. Patients should ask whether the price includes potential additional services. After all, the point of a diagnostic colonoscopy is to find and, if necessary, treat any lesions that may cause problems, no matter how many are found.
Xiao said everything should be easier for patients: “You don’t have to be a medical billing expert to know how much you’re going to pay.”
“This Month’s Bill” is a crowdsourced survey by KFF Health News and The Washington Post’s Well+Being that provides an in-depth analysis of health care costs. Since 2018, this series has helped countless patients and readers reduce their healthcare costs and has been cited at statehouses, on Capitol Hill, and in the White House. Do you have a confusing or exorbitant medical bill that you would like to share? Tell us about it!
KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of KFF’s core operating programs and an independent source of health policy research, polling, and journalism. is. Click here for more information about KFF.
Subscribe to KFF Health News’ free morning briefings.
This article was first published in KFF Health News and is republished here under a Creative Commons license.
