How much does a colonoscopy cost in California? From $0 to $7,240, we learned from our PriceCheck community. Though preventive care is supposed to be covered under the Affordable Care Act, people are paying a lot for their colonoscopies, we learned — and the range of payments by insurers is surprisingly wide.
Charges ranged from $1,200 to $7,240.
Insurers paid anywhere from $1,800 to $7,126.80 for a colonoscopy (see chart below).
Some individuals paid nothing, but some paid a lot of money $1,200, $1,344, $1,500 and even $2,255, even if they were insured — and many of them for reasons they couldn’t fathom.
Our project, PriceCheck, with partners KQED public radio in San Francisco and KPCC/Southern California Public Radio in Los Angeles, was funded by the John S. and James L. Knight Foundation. We have collected prices for common procedures, put them in an interactive tool on our websites, and then invited our community members to share their concerns and their prices.
Specifically, we asked people to tell us about their mammograms, MRI’s, IUD’s and diabetic test strips. We made our interactive widget so that people could share any procedure from the group of 8,400 medical codes in the HCPCS system of coding used by the government. Here are our collected blog posts.
We did not specifically ask people to send in their colonoscopy bills, but they did anyway — perhaps because that was the biggest recent charge they had encountered (click on chart to enlarge).
What surprised us: the wide range of payments from insurers for what was apparently a fairly similar procedure.
What else surprised us: So many people paid something out of pocket for a colonoscopy, though this is supposed to be one of the 10 essential benefits covered by insurance policies in compliance with the Affordable Care Act. Colorectal cancer screenings are supposed to be covered at no cost by A.C.A-compliant plans, but we have heard here and elsewhere (in our PriceCheck mammogram survey, for example) that people are being asked to pay for preventive services. This seems against the letter and the spirit of the law. Here’s a toolkit from the National Women’s Law Center that covers just about every eventuality. What’s covered, how it’s covered, sample scripts and letters.
They may not exactly be the same procedure. One might have had full-on anesthetic, or higher lab bills. But generally the range of prices is enormous.
We’re not sure about the coding. Everybody knows the practice of medical coding is complicated and arcane. Entire businesses are built on clearing up coding problems, or on “upcoding,” the industry word for making sure that every last penny is extracted from a potential payer by choosing the right CPT code. The list here to the right shows the many codes a community member would have to choose from if he or she typed “colonoscopy” into the procedure box.
So if our community members picked CPT code 44388 when they might have actually had a 45380, we are not completely surprised. Also, that single code never encompasses all the different pieces of a colonoscopy, which as far as we know include doctor’s fee, anesthesiologist, lab fees, facility fee (if any), and perhaps a pre-procedure consultation (mine was charged at $250). Also, the bills often do not have any code on them at all, leaving a lot to guesswork.
We didn’t ask to see all the bills. About 70-80 percent of our community members supply emails, and we are able to contact people and ask for bills.
Even lab bills can vary widely. My lab bills were $90; my girlfriend’s, $250.
Not one, but two procedures
One person said the procedure included a colonoscopy and an endoscopy. The comment: “I was anaemic and my doctor suggested a colonoscopy and endoscopy to eliminate the possibility of polyps. I found out about the $2000 deductible the night before the procedure when Kaiser called me to let me know what to expect the next day. Despite my trying to pin them down, I just could not get a complete final price from anyone.”
The charge: $7,577.55. Insurance paid $3,921.77. Our community member, clearly on a high deductible plan, paid $3,655.78.
At first we were puzzled about the high price, but then we realized this is not a preventive colonoscopy (which is supposed to take place without a co-insurance or deductible), but then we realized this is a diagnostic colonoscopy, or a “sick-person visit,” which is not preventive.
We noticed here, as elsewhere, that there are some entries that are crystal clear, and in other places there are errors in data entry.
At UCSF San Francisco, the charge of $3,714 was accompanied by an “insurer paid” notation of $2,175. The community member wrote: “UCSF invoiced at the retail rate; insurance company paid for negotiated rate.”
The bottom entry, with the blue box around it, shows some of the pitfalls of crowdsourced data. The comment says clearly that the charged price was $1,341 and the insurance rate was $593.16, so we’re not sure who paid what to whom. Also looking at a $593.16 colonoscopy in the context of the other payments, we felt certain in saying that this must have been only a partial bill –- perhaps the doctor’s fee only, omitting any other charges.
O.K., so how much does a colonoscopy cost? Here are some cash prices
Interestingly, also, one person told us the price to him would be $8,713. He explained, “The above amount is the average of the range ($6,099 – $11,327) this facility quoted for a self pay procedure. They stated they could not narrow it down, due to too many variables. They said the cost they’d negotiated with my insurance carrier was less, but they refused to tell me the negotiated fee. If I had the procedure at their facility, they informed me, my health insurance would cover 100% of the undisclosed fee.”
He explained further by email: “The issue of cost arose when I went to my regular GI doctor for a pre-procedure exam and was informed that the clinic he and his partners had operated (where my last procedure was done 5 years ago) had been sold to another company. Although my doctor can still perform the procedure there, the facility no longer contracts with my insurance provider…. If I wanted my procedure done there, I would have to pay for it fully out of pocket. I was also told that he had privileges at a hospital which contracts with my insurance carrier (the hospital I identified in my submission), and if I wanted to have the procedure done there it would be covered 100% by insurance. That set me about the task of looking into cost comparisons.
“I was quoted $975, flat fee, to have the procedure done at his former facility. You, of course, saw what the hospital quoted me (~$6,000 – $11,350). … Plus, I am shocked they couldn’t provide a more precise estimate than they did for such a routine and common procedure. And, too, there’s the fact that although the cost to my insurance provider is a lower contracted fee, they refused to divulge that contracted cost.
“If cost were not a consideration… I would prefer to have the procedure done at the physician’s former facility. It’s small, personal, competent, and well-staffed. … I am completely unfamiliar with the alternative hospital. No one I know is familiar with it, or has ever received care there. It may very well be a perfectly fine facility, I wouldn’t know. … it’s a full-service hospital with all the overhead and bureaucracy that comes with large healthcare facilities. But, it’s ‘free-to-me’ if I choose to have the procedure done there!”
The takeaway: Questions to ask
As we always say, know before you go. Questions to ask:
- What all is covered? Doctor’s fee, anesthesiologist, lab fees, anything else?
- Will this all be covered by my insurance? If not, what will not be covered? Can I get that in writing? (if you’re insured)
- Will there be a facility fee? Does there have to be, or can it be done at another place without a facility fee?
- What kind of anesthesia are you planning to use? How much will it cost?
- Some places choose to pay only for “twilight” anesthesia, while others want full general anesthesia. Do I have a choice, and what’s the price difference?
- If there is a separate anesthesiologist, is that person part of my network (if you’re insured)?
- Will all lab tests be done at a participating lab?
- Do you require a pre-procedure consultation? How much will that cost? Can I skip that?
- How about the stuff you have to take to empty your system before the procedure? How much is that going to cost? is it covered by insurance?
Take notes, and take names and phone numbers. If you need to question a bill later, it’ll be much easier.