Tom Kontos 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 he became more concerned when the bleeding continued for several weeks.
The Chicago Health Care Consultant contacted his physician at Northwestern Medicine, who referred him for a diagnostic colonoscopy, at least in part because Kontos, 45, had a family history of colon problems.
“I work out a lot,” he said. “But my partner said that's not normal. My primary care doctor said, 'Given your family history, let's bring you in.'”
Northwestern Memorial Hospital asked him to prepay $1,000 out of his own pocket, and he underwent the procedure in June.
Then the bill came.
medical procedure
Colonoscopy is performed in the United States more than 15 million times one year. Colorectal cancer rates are increasing, especially among young people.
The procedure, which is also the recommended screening for people age 45 or older, involves examining the large intestine using a tube with a video camera that can also collect tissue samples.
It usually takes less than an hour, including taking the patient's history, administering anesthesia and monitoring their recovery, said Glenn Littenberg, MD, a physician who recently chaired the reimbursement committee of the American Society of Gastrointestinal Endoscopy. Another hour is spent.
According to Kontos' medical records, the gastroenterologist who performed his colonoscopy described it as “not difficult”. They performed biopsies and removed small growths called polyps from two locations and identified larger internal hemorrhoids, which are swollen veins.
Biopsy samples were sent to pathology for testing and were found to be precancerous. But the gastroenterologist reported finding no evidence of cancer, and after reviewing the pathology report, he concluded that the probable cause of the bleeding was hemorrhoids.
final bill
The hospital charged a total of $19,206 for the procedure, including physician fees. The insurer negotiated the price to $5,816 and paid $1,979, leaving the patient's share at $4,047. (It was not clear why the payment went slightly higher than the negotiated price.) After Kontos paid $1,000 upfront and $1,381 right after the procedure, the hospital said it still owed $1,666 .
Billing problem: Colonoscopies that detect polyps cost more
When Kontos received his itemized bill he was shocked and angry. “I said, 'I don't understand this.' Then I started researching the cost.”
He asked the hospital how much it charged for a diagnostic colonoscopy and was told a cost estimate was sent to him through their online patient portal before the procedure.
The estimate, which took into account his deductible of $3,200, listed the total price as $7,203, with an out-of-pocket bill of $2,381. He asked Northwestern why the charges were almost three times higher than anticipated and why their out-of-pocket share was almost double.
A big reason was revealed in an explanation of benefits (EOB) statement from Kontos' insurance company, Aetna: Northwestern had charged $5,466 each for the two colonoscopies. And there were two fees for gastroenterologists – $1,535 and $1,291.
The first procedure was listed as “colonoscopy and biopsy”, while the second was listed as “colonoscopy w/lesion removal”. Aetna's negotiated member rate reduced the first $5,466 hospital charge to $3,425, while reducing the charge for the second procedure to $1,787 – $1,638.
Neither the bill nor the EOB explained why the second procedure was listed at a lower price.
After examining Kontos' bill, Littenberg said that because of the extra work, it is standard to bill for two colonoscopies if the provider removes two or more polyps in different ways. He added that, as in this case, hospitals typically use a modifier code that reduces the amount charged for a second-billed colonoscopy, so they only charge for the additional work.
“How do you explain this in sensible words that anyone can understand?” Littenberg said.
Even with that deduction, Littenberg said, he thought Contos' total cost of $4,047 was “very high, although not rare for larger academic centers.”
Kontos' insurance documents show that Aetna's negotiated rate for his colonoscopy at Northwestern was more than double the insurer's average negotiated rate for the same procedure at other Chicago-area hospitals, said Forrest, director of quantitative research at Turquoise Health. According to Jio, which is a company. Health care price data.
In conversations with Northwestern and Aetna representatives, Kontos asked why he was charged for two colonoscopies. A representative from Northwestern said that because of the modifier code, he was not actually being billed for the two procedures, which Kontos found surprising.
“I told Northwestern, 'I'm not paying that, and I don't care if you send me to collections,'” he said. He filed appeals with the hospital and Aetna but was ultimately told the billing was correct.
Resolution
In an email, Kontos told the billing department that his charges were “ridiculously high.” A representative responded that Northwestern's pricing is in line with other academic medical centers in Chicago and “not negotiable” — and that her account would be turned over to a collections agency.
CVS Health spokesman Philip Blando said in a written statement to KVS Health News that Kontos' claims were “exactly paid” by Aetna, declining further comment. (CVS Health owns Aetna.)
Northwestern did not respond to multiple requests for comment.
Kontos said he has written to his doctor that he regrets leaving them and Northwestern altogether because of the health system's high costs.
He said he still experiences symptoms from time to time, which he relieves with over-the-counter Preparation H. A one-ounce tube of the ointment costs $10.99 at CVS.
takeaway
To get a colonoscopy at a lower cost, Littenberg said, patients should consider going to a freestanding endoscopy center or ambulatory surgery center that is not affiliated with a hospital. A study of 2023 found that ambulatory surgery centers billed insurers an average of $1,030 for a colonoscopy with biopsy or removal of a polyp, while a hospital billed $1,760.
monthly bill
To find out how much a diagnostic colonoscopy might cost, patients can consult a hospital's pricing website and an insurer's cost-estimator website, both required by federal price transparency rules.
patients can also see good faith estimate Of cash value, which may be lower than the price for patients who use insurance to pay for a procedure. Also, they can check the prices through websites like turquoise health And proper healthThat is derived from federal price transparency data or claims data from insurers.
Still, if the colonoscopy finds one or more polyps that need to be removed and biopsied, the actual cost may be higher than the estimate, which happens in at least 40% of all colonoscopies, Littenberg said. Patients should ask if the price includes those potential additional services. After all, the purpose of a diagnostic colonoscopy is to detect and, if necessary, treat lesions that may cause problems – regardless of the number found.
This should all be easy for patients, Xiao said: “You don't have to be a medical billing expert to know what you're going to pay.”
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