He went in for a colonoscopy. The hospital charged $19,000 for two.
Tom Contos is an avid runner. When he started experiencing rectal bleeding in March, he thought exercise might be the cause and tried to ignore it. But as the bleeding continued for weeks, he became increasingly concerned.
The Chicago healthcare consultant contacted his doctor at Northwestern Medicine, who recommended he undergo a diagnostic colonoscopy, in part because the 45-year-old Contos had a family history of colon problems.
“I work out a lot,” he said. “But my partner said this wasn’t normal. My primary care doctor said, ‘Given your family history, let’s get you in.'”
Northwestern Memorial Hospital required him to pay $1,000 upfront out of pocket, and he underwent surgery in June.
Then the bill came.
medical procedure
Colonoscopies performed in the United States More than 15 million times One year. The incidence of colorectal cancer is rising, especially among younger people.
The procedure, also a recommended screening for people 45 and older, involves examining the large intestine using a tube with a camera that also collects tissue samples.
Dr. Glenn Littenberg, who most recently chaired the American Society for Gastrointestinal Endoscopy’s reimbursement committee, said it typically takes less than an hour, plus an additional hour to take the patient’s history, administer anesthesia and monitor his recovery status.
The gastroenterologist who performed the colonoscopy described it as “not difficult,” according to Contos’ medical records. He biopsied two spots and removed small growths called polyps and discovered large internal hemorrhoids, which are swollen veins.
The biopsy sample was sent for pathology testing and was found to be precancerous. But the gastroenterologist reported finding no evidence of cancer, and after reviewing the pathology report, he concluded that hemorrhoids were the likely cause of the bleeding.
final bill
The hospital billed a total of $19,206 for the procedure, including physician fees. The insurance company negotiated the price to $5,816 and paid $1,979, leaving the patient’s share of $4,047. (It’s unclear why the payments added up to slightly more than the negotiated price.) After Contos paid $1,000 up front, plus $1,381 immediately after the surgery, the hospital said he still owed $1,666.
Billing issues: Colonoscopies that find polyps cost more
When Kontos received the detailed bill, he was shocked and angry. “I said, ‘I don’t understand this.’ Then I started looking at the costs.”
He asked the hospital how much it would cost for a diagnostic colonoscopy and was told he had received a cost estimate through the online patient portal before the procedure.
The estimate takes into account a $3,200 deductible and lists the total price at $7,203, with out-of-pocket expenses of $2,381. He asked Northwest why it was being charged nearly three times the estimate and why his out-of-pocket costs were nearly twice the estimate.
An explanation of benefits (EOB) statement from Contos’ insurance company, Aetna, revealed a big reason: Northwestern charged $5,466 for two colonoscopies. There are two fees for a gastroenterologist: $1,535 and $1,291.
The first procedure was listed as “colonoscopy and biopsy,” while the second procedure was listed as “colonoscopy and removal of lesions.” Aetna negotiated membership rates that lowered 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 procedure is listed at a lower price.
After reviewing Contos’ bill, Littenberg said it’s standard practice for providers to bill for two colonoscopies because of the extra work required if they remove two or more polyps in different ways. He added that in such cases, hospitals often use modification codes to reduce the amount charged for the second colonoscopy, so they only charge for the additional work.
“How do you explain this in reasonable language that anyone can understand?” Littenberg said.
Littenberg said that even with that reduction, he believes Contos’ total out-of-pocket cost of $4,047 is “not unusual for a large academic center, but still a lot.”
Forrest Shaw, director of quantitative research at Turquoise Health, said Contos’ insurance documents show Aetna’s negotiated rates for colonoscopies at Northwestern are higher than what insurers charge for other Chicago-area hospitals. More than twice the median negotiated rate for the same procedure. Healthcare price data.
In exchanges with Northwestern and Aetna representatives, Contos asked why he was charged with having two colonoscopies. A representative from Northwestern said Contos was confused that he had not actually been paid for the two surgeries because of the revised code.
“I told Northwestern, ‘I’m not going to pay, and I don’t care if you send me to collect it,'” he said. He appealed to the hospital and Aetna, but was ultimately told the bill was correct.
resolution
Contos told the billing department in an email that its charges were “ridiculously high.” A representative responded that Northwestern’s pricing was in line with other Chicago academic medical centers and “non-negotiable,” and that his account would be turned over to a collection agency.
CVS Health spokesman Phillip Blando said in a written statement to KFF Health News that Aetna has “accurately paid” Contos’ claim but declined further comment. (CVS Health owns Aetna.)
Northwestern University did not respond to repeated requests for comment.
Kontos said he wrote to his doctor who regretfully gave up on him and left Northwestern solely because of the high prices of the medical system.
He said he still had periodic symptoms, which he took over-the-counter medication Preparation H to relieve. An ounce of the ointment is $10.99 at CVS.
takeout
To get a colonoscopy at a lower price, patients should consider going to a freestanding endoscopy center or an ambulatory surgery center not affiliated with a hospital, Littenberg said. 2023 study The study found that ambulatory surgery centers charged insurance companies an average of about $1,030 for a colonoscopy biopsy or polyp removal, compared with $1,760 for hospitals.
This month’s bill
To find out how much a diagnostic colonoscopy costs, patients can check the hospital’s pricing website and the insurance company’s cost estimate website, both of which are required by federal price transparency rules.
Patients can also search good faith estimate Cash price, which may be lower than the price for patients who use insurance to pay for the procedure. Additionally, they can check prices through the following websites: Turquoise Health and fair healthfrom federal price transparency data or insurance company claims data.
Still, if the colonoscopy reveals one or more polyps that require removal and biopsy (which occurs in at least 40 percent of colonoscopies), the actual cost may be higher than estimated, Littenberg said. Patients should ask whether the price includes those potential additional services. After all, the purpose of a diagnostic colonoscopy is to find and, if necessary, treat lesions that may be causing problems—no matter how many are found.
Shaw said this should be easier for patients: “You don’t have to be a medical billing expert to know what you’re going to pay.”
This month’s bill is a crowdsourced survey KFF Health News and Well+Being by The Washington Post Analyze and explain medical costs. Since 2018, this series has helped many patients and readers reduce their medical bills and has been cited in statehouses, the U.S. Capitol, and the White House. Do you have a confusing or overwhelming medical bill you’d 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 – an independent source of health policy research, polling and news. Learn more about Cave.
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this article first appeared in KFF Health News and republished here under a Creative Commons license.
