How much an insurance provider will pay toward a colonoscopy all depends on how the procedure is coded. Medical codes are used to describe diagnoses and treatments and help determine costs and reimbursements. A screening colonoscopy is coded and covered differently than a diagnostic colonoscopy.
A screening colonoscopy is a colonoscopy performed on an asymptomatic (no symptoms) patient of screening age to examine for colon polyps or cancer.
Providers should cover screening colonoscopies as part of Affordable Care Act (ACA) preventive health care, but there are certain conditions that have to be met. Click here to use our simple infograph to find out if you are eligible for a free or low-cost colonoscopy. Everyone, no matter what their history, should be screened started at age 50. African Americans are at a higher risk and should start at age 45. If you have a first-degree relative who has been diagnosed with colon cancer or polyps, it is important to be screened earlier. Please refer to "Family History Could Cover Your Colonoscopy."
Before scheduling your screening colonoscopy, you should make a list of questions to ask your insurance provider to help determine your financial responsibility. Some of these questions should include, but not limited to:
Depending on your plan, most insurance companies pay for the actual screening procedure at 100 percent. However, if you have anesthesia or pathology, there may be cost sharing involved. This depends entirely on your individual plan. Even if you have no personal or family history of colon cancer or polyps and this is your baseline colonoscopy, it's important to ask your provider about medical coverage if a polyp is found and needs to be removed. Remember, over 80 percent of colon cancer cases are individuals with no family history of polyps or colon cancer.
A diagnostic colonoscopy is a procedure that is requested when symptoms are present or when another screening procedure comes back positive. Diagnostic colonoscopies are not addressed under the Affordable Care Act, so it is imperative that you call your insurance provider to inquire about coverage and out-of-pocket expenses. You will ask your insurance provider the same questions listed above, but you will want to request information about your financial responsibility for the procedure itself as well as anesthesia and polyp removal (if required) and if you need further care.