After 14 years of procrastination, Dave Southard finally went in for his first colonoscopy at age 64.
But after spending half a year trying to correct what he believes is a billing error, Southard’s first colonoscopy may also be his last. This despite the fact that the doctor found and removed polyps, meaning he is at greater risk for future problems.
“The patient should not have to fight like this. They shouldn’t be kicked around from person to person saying, ‘I can’t help you,’” said Leslie Prahar, Southard’s wife. She handles the family’s insurance issues, and was so outraged that she contacted the Inquirer for help and to alert others who may encounter the same problem.
“I felt like I was banging my head against the wall. Nobody was listening to me and I had to reach out to somebody with more power than me,” she said.
Routine colonoscopies are among the basic screening tests that are supposed to be covered in full by private insurance for adults aged 50 to 75. So when Southard, now 65, got a bill for $302, he and his wife snapped into action.
The Broomall couple drove to the Crozer-Keystone Health System location listed on the bill and were told they needed to talk to the provider’s office directly. Crozer Gastroenterology Associates sent them upstairs to a billing office, which pointed them to a different location that handled medical records.
Prahar also tried their insurer, Independence Blue Cross, but was told the bill had been processed correctly and that if there was an error in how it was submitted, the doctor’s office would need to fix it.
Over the next several weeks, Southard and Prahar ping-ponged from one Crozer-Keystone office to the next.
“They all said, ‘Sorry, but you owe it.’ That was all,” said Prahar, 62. “No, I don’t owe it. Why won’t anyone listen to me?”
Under the Affordable Care Act, colonoscopies are covered by private insurance with no copay when the purpose is to screen for cancer in a person who is at average risk — even if a polyp is removed, said Caroline Powers, a director of federal relations for the American Cancer Society. So long as the procedure is performed by an in-network provider, it should not cost the patient anything, not even a co-pay, even if the person hasn’t reached the deductible.
Right after the ACA took effect, patients frequently got caught in a loophole that allowed them to be billed if a polyp was removed, turning their screening test into a diagnostic one. The government later issued a clarification that the procedure must be covered in full — including polyp removal and testing — so long as it was originally intended as a screening colonoscopy.
Medicare does not have the same rules. Medicare beneficiaries will be responsible for a share of the bill if a polyp is removed during their screening colonoscopy.
“Going in, that can be a deterrent,” said Stephanie Krenrich, who also works as a director of federal relations for the American Cancer Society.
That’s concerning, she said, because routine screening is highly effective in preventing colorectal cancers. But it’s invasive, involves anesthesia, and the prep is unpleasant, so getting people to go for one is hard enough without billing concerns.
Crozer billed Southard’s insurance $1,289 for a colonoscopy with removal of a tumor, polyp or lesion by snare technique and $854 for a colonoscopy with a biopsy. Doctors may bill for two colonoscopy codes if they removed multiple polyps using two different techniques; however, it’s unclear exactly what happened in Southard’s case because Crozer has refused to explain it to him or to the Inquirer.
The first was billed using a “modifier code” to indicate to the insurer that even though a polyp was removed, the procedure was considered preventive, according to Independence Blue Cross, which reviewed the charges at the Inquirer’s request. The plan negotiated a rate of $625 for the procedure and paid it in full.
The second procedure did not have a modifier code and was processed according to the cost-sharing terms of Southard’s plan. Independence’s negotiated rate was $508. The plan paid $206 and Southard got a bill for $302.
“In order for a colonoscopy to be considered a preventative service, it must be coded with the correct modifiers or diagnosis codes,” Virginia Calega, a physician and vice president of medical affairs at Independence, said in a statement. “After reviewing this member’s claim, it is apparent that there were two separate procedures performed and that the member’s cost-sharing was applied because only one of the two services listed contained the information (modifier/diagnosis code) needed for us to know it was preventative.”
Crozer declined to comment on Southard’s case or explain its approach to billing for his colonoscopy, but a spokesperson said the health system investigates any patient questions about bills.
“Financial counselors are available at all Crozer-Keystone sites, and they will investigate and make sure necessary corrections are made before submitting a corrected claim to the insurance carrier,” Andrew Bastin, an assistant vice president of marketing and corporate communications for Crozer, said in an email.
Crozer looked into Southard’s bill, but never provided a reason for the diagnostic charge, so the couple kept challenging it, Prahar said.
In January, after fighting the bill for seven months, they believed that they had no choice but to pay up. It had been sent to a collections agency in September and the retired couple didn’t want their credit rating to suffer.
She wrote on the form accompanying her check, “Paid in protest.”
Negotiating medical bills or getting an explanation of charges can be exceedingly difficult for patients. Yet as out-of-pocket costs continue to rise, more patients are undertaking the task.
“The general attitude of people in finance departments is they treat you as the amateur that you usually are,” said Akshay Gupta, a partner at CoPatient, a Connecticut-based company that helps patients challenge medical bills.
Insurance companies routinely challenge charges that would require them to pay more for care than the plan believes is necessary.
But high deductibles, coinsurance and other cost-sharing plan designs have shifted more costs to patients, leaving them, in many cases, to duke it out with providers directly, Gupta said.
“These aren’t mistakes that just materialized now. They’ve always been around, but there were other companies doing something about it,” he said. “Now it’s left to the patient to figure out.”
After being contacted by the Inquirer, Crozer called Prahar and Southard to say it was reviewing Southard’s case.
But the couple say that’s too little, too late to change his mind about future colonoscopies.