Physicians Working to Understand Billing Guidelines

Unclear policies for colonoscopy billing practices are creating new challenges for patients and physicians alike.

Research published in December of 2021 in JAMA Network Open reveals that patients and gastroenterologists are facing confusion over changing billing practices. The study, which focuses on out-of-pocket costs for colonoscopies after non-invasive colorectal cancer screenings, sheds light on the issue.

Data was analysed from 88,000 people with commercial insurance along with Medicare coverage. These individuals all received stool-based tests for colorectal cancer. From this cohort, 15.8 percent of individuals had colonoscopies following the non-invasive testing, while 57.8 percent of individuals had one or more polyps removed during their subsequent colonoscopy.

The research shows that “[Out-of-pocket] costs for colonoscopy were incurred by nearly half of those who were commercially insured and by more than three-quarters of those covered by Medicare.” Out-of-pocket costs increased further for patients who received a polypectomy.

Change in Practices

Private insurers are required to cover colonoscopies following positive results from non-invasive screening tests. However, polyp removal has complicated the billing process. Colonoscopies which have been billed as diagnostic have at times cited polyp removal as a factor of this decision. This change in billing codes does not align with Centers for Medicare and Medicaid Services (CMS) guidelines. These state that polyp removal should be considered as part of screening colonoscopies.

Patients are not the only group affected by a lack of clarity in billing practices, with gastroenterologists reporting concerns over a decline in reimbursement for colonoscopies for Medicare and Medicaid patients.

Additionally, patients are more reluctant to arrange follow up treatments because of billing confusion. Many are fearful they will face additional costs they cannot afford. Patients with concerning symptoms are pursuing less costly non-invasive testing as an alternative to advised endoscopic evaluation.

Reducing Anxiety

Gastroenterologist Dr. Alejandro Pruitt spoke to Becker’s about his concerns on the topic. “Unfortunately, patients are penalized with deductibles that are obscenely high or coinsurance which they cannot afford. Many are lost to follow up when they are informed of their financial responsibility despite our efforts to try and arrange for less costly, and often less sensitive, non-invasive tests.”

To help reduce this anxiety, newly released guidance on January 13^th, now requires private insurers to cover colonoscopy costs as needed as a follow-up to a non-invasive screening test. Gastro.org adds that this addition will help prevent patients from receiving these surprise bills following a positive stool-based test.