No Simple Answers For Surprise Bills After Procedures

Question: I had a colonoscopy and was told it was covered in full, then I got a bill for it. Should I pay for it?

Answer: There are many procedures and tests that Original Medicare (Part B) covers in full, for example; many preventatives tests like Mammograms, Colonoscopies, Bone Mass Measurements and some vaccines fall into this category. Your question references the Preventative Screening of the Colonoscopy and other Colorectal Cancer Screenings.

Original Medicare covers Preventative Colonoscopy Screening every 120 months (10 years). When an individual is considered high risk for Colorectal Cancer, they can get a preventative colonoscopy screening done every 24 months and still be covered in full by Original Medicare.

When planning for your Colonoscopy many individuals assume that because it is “covered” it will be paid in full by their insurance. Medicare Part B will only pay this cost in full if you are new to Medicare and therefore hasn’t ever paid for a colonoscopy for you, or your last Medicare covered colonoscopy was more than 120 months ago.

If you had a colonoscopy less than 120 months ago, your Original Medicare will cover this procedure, but only pay part of the cost of that procedure. In past years Original Medicare covered 80% of the cost. In the coming years this cost share will be changing. In 2023 the cost share for this Colonoscopy has changed to 85% covered by Medicare. That means the newly lowered 15% cost share may be covered by your secondary insurance or yourself.

Even when your colonoscopy is preventative in nature and your last was more than 120 months, it could be covered in full, but there are situations where you may have to cover part of the cost. Your colonoscopy was scheduled as a preventative procedure, but during this procedure they found something, maybe a polyp that was removed, or tissue that was sampled for testing. This situation changes the colonoscopy procedure to diagnostic in nature. This would change that preventative procedure to a diagnostic procedure and your free colonoscopy just moved to the new 15% cost share in 2023. From 2023 to 2026, 15% will be the cost share. In 2027 to 2029 it will decrease to 10% and in 2030 the coinsurance will be waived completely as the reduction goes to 0% cost share.

This can be frustrating in trying to determine what costs you will be seeing in the future. You anticipate a procedure is free and then when something is found to be wrong, you now have additional costs. If you have a Medicare Supplement Policy (Medigap) it may cover all or part of this 15% cost share depending on the Medigap letter plan you have (all but Plan K & L cover this cost in full).

Your question was “Should I pay the bill?” I never recommend paying any medical bill until you have received your Explanation of Benefits, (EOB’s) and Medicare Summary Notices (MSN’s). You should check your bills with these statements to be sure the bill matches what your insurance determines you owe.

If you have a Medicare Advantage Plan your plan must cover preventative procedures that Original Medicare covers, but it will cover it differently. The Preventative procedures are covered in full much like Original Medicare does. The diagnostic procedures usually have a cost share. This cost share could be a flat amount $300 for outpatient surgery, it could also be a percentage 20% of the insurance negotiated cost for that procedure. You can review your plans outline of coverage in the material they sent to you in the mail. You can also call the customer service number on the back of your insurance card to determine what this procedure will cost.

It is interesting to learn that Original Medicare is reducing the cost share to Medicare recipients and the secondary insurance companies from 20% to 15% and eventually down to 0%. I find that few individuals will be impacted by this reduction as they have secondary insurance. It appears that the insurance companies that are secondary to Original Medicare will save the most for these procedures.

Senior Life Matters is a community based program sponsored by Lutheran Jamestown. For questions and concerns or to reach Janell Sluga, GCMC, call 716-720-9797 or email SLM@lutheran-jamestown.org.


Today's breaking news and more in your inbox

I'm interested in (please check all that apply)
Are you a paying subscriber to the newspaper? *


Starting at $4.62/week.

Subscribe Today