One of the major benefits of the Affordable Care Act (ACA) was the preventative care coverage. This has led many of us to take the wise step in early detection screening. Yet, there are still things to know to be a wise health care consumer when going in for one of these exams:

#1) This screening test is only covered 100% under ACA compliant health insurance. Other insurances that are outside the regulations of the ACA do not have this benefit.

#2) Most of us will be offered sedation to make the entire experience more comfortable.

-Standard sedation is usually covered by insurance and is given by the doctor’s nurse. This usually involves benzodiazepines (Valium or Versed) plus some pain medications. This is called “conscious sedation”, you’ll be awake but you won’t be able to remember anything

*The side effects are dry mouth and sleepiness afterward (probably for the rest of the day).

*Due to sleepiness, it’s good to have whoever goes with you to either take notes or record the doctor on your phone (as you won’t be able to remember anything the doctor says), so that you can review the results of your exam when you’re alert again.

-General anesthesia sometimes offered and it may or may not be covered by insurance. Check with the clinic business manager before agreeing to this amount of sedation.

(If not covered, this usually amounts to $900-1000 out-of-pocket if you haven’t met your deductible. If you have hit your deductible, it might still be a large amount as many anesthesiologists are out-of-network. In-network benefits will probably be just a copay if the deductible has been satisfied. Hint: If the business manager says it is covered, get that person’s business card and write the copay amount on the back of the card for future reference!)

*Propofol is usually the drug used. It allows the patient to wake up alert and able to function almost immediately after the procedure.

*General anesthesia requires an anesthesiologist who usually supervises a nurse anesthesiologist who administers this.

*It is slightly more risky than regular sedation.

#3) Be sure that check your EOB (Explanation of Benefits) from your insurance coverage after the colonoscopy to see that the procedure itself was covered 100%.

*None of us are perfect, so it’s fairly typical for the doctor to find a little bump or some sort of unusual looking area

*The doctor will usually take a biopsy to be sure and here’s the tricky part:

*Sometimes the codes on the colonoscopy get mixed up and they show a “diagnostic” procedure (in other words, they found something) instead of a “screening” or preventative procedure.

*If the coding/billing shows your procedure as “diagnostic” it is subject to your deductible and you might have to pay out-of-pocket costs. This is a mistake–all colonoscopies should be “preventative” and covered at 100%, no matter what the patient’s deductible is.

 *Then if biopsy gets taken and sent off to a pathology group somewhere else and sometimes a bill arrives from this other group. Once again—this is a “preventative” procedure, which should be covered by insurance, so if you get a bill from a pathology group (usually $200-300), you will need to call them to remind them that their services should be covered 100% as a screening test as well as check your insurance EOB to look for any mistakes.

After checking all these things, this should help make the financial side of getting a colonoscopy clearer and avoid the unpleasantness of a large surprise medical bill in the mail afterwards. 

And as always, if you have any questions, just give me a call!

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