Surprise Billing for Colonoscopy: The Scope of the Problem

“Federal law eliminates consumer cost sharing for multiple methods of colorectal cancer screening, including colonoscopy when done by an in-network provider. However, some patients having screening incur considerable out-of-pocket costs because out-of-network bills are not included in federal mandates.

[..] A claims database from a large national insurer was queried for commercially insured patients aged 18 to 64 years who had a colonoscopy between 2012 and 2017. Cases coded as elective with a stay of 1 day or shorter were included. The analysis was restricted to cases in which both the facility and the endoscopist were in-network. [..] The typical in-network price excluded expected patient cost sharing (for example, deductibles) and was price-standardized by the data vendor to reflect the national average payment for the same service.

[..] Between 2012 and 2017, we identified 1,118,769 elective colonoscopies with in-network endoscopists and facilities; of these, 12.1% (95% CI, 11.2% to 13.1%) (n = 135,626) involved out-of-network claims. The median potential surprise bill was $418 (interquartile range, $152 to $981). Out-of-network anesthesiologists were involved in 64% of cases (median potential surprise bill, $488 [interquartile range, $145 to $1186]); out-of-network pathologists were involved in 40% (median potential surprise bill, $248 [interquartile range, $153 to $554]). The likelihood of an out-of-network claim was significantly higher when an intervention was done during colonoscopy than in cases without intervention (13.9% vs. 8.2%; difference, 5.7% [CI for difference, 4.9% to 6.5%]). When interventions were performed, 56% of potential surprise bills involved anesthesiologists and 51% involved pathologists. In cases with visual inspection only, 95% of potential surprise bills involved anesthesiologists.

[..] Our findings show that nearly 1 in 8 commercially insured patients who had an elective colonoscopy between 2012 and 2017 incurred an out-of-network claim, averaging hundreds of dollars more than the typical insurance payment. Particularly concerning was that 1 in 12 procedures that did not have an associated intervention had an out-of-network claim. This outcome is disconcerting because Section 2713 of the Patient Protection and Affordable Care Act eliminates consumer cost sharing for screening colonoscopy and because a recent Federal Reserve study reported that 40% of Americans do not have $400 to cover unexpected expenses.

[..] In the short term, endoscopists should also consider using established cost-saving strategies, such as conscious sedation and the “resect and discard” approach, to biopsy specimens. In the longer term, we must enhance ongoing reform efforts to remove consumer cost sharing for all clinically indicated care associated with colonoscopy. In the meantime, it is essential to develop tools that provide patients an estimate of their financial responsibility before their colonoscopy is done and better protect them from potential financial harm.”

Full article, Scheiman JM, Fendrick AM, Nuliyalu U et al. Annals of Internal Medicine 2020.10.13