Colonoscopy, did something change?

[somarco]

I had my wife covered with UHC advantage plan. She had a colonoscopy and it was paid 100%. I switched to Aetna advantage plan and she had another colonoscopy she got billed $260. I called Aetna and they said because they removed a polyp it was considered surgery. Last year I received a list of changes to their plan and they now pay as preventive care even if a polyp is removed. I have an Aetna advantage plan and I will be moving from it the day I can.

So, you are saying SOME MAPD plans pay claims differently from original Medicare?

Or are you saying you really have no idea how claims are adjudicated?

You pay nothing for this test if your doctor or other qualified health care provider accepts An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.
However, if a polyp or other tissue is found and removed during the colonoscopy, you may pay 20% of the In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference.
Colonoscopy Screening Coverage

 

[Chazm]

So, you are saying SOME MAPD plans pay claims differently from original Medicare?

Or are you saying you really have no idea how claims are adjudicated?

You pay nothing for this test if your doctor or other qualified health care provider accepts An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.
However, if a polyp or other tissue is found and removed during the colonoscopy, you may pay 20% of the In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference.
Colonoscopy Screening Coverage

It’s sad he doesn’t have an agent, or competent one, to explain this. Hell switch her for no reason at all.

 

[ICACharleston]

I year or two ago UHC made a big deal out of paying 100% for colonoscopies, including polyp removal. I’ve been selling UHC MA plans since 2008 and never heard a complaint about being charged for polyps. Possibly it isn’t something people are likely to complain about.

 

[somarco]

Medicare covers screening colonoscopies once every 24 months if you’re at high risk for colorectal cancer. If you aren’t at high risk for colorectal cancer, Medicare covers the test once every 120 months
Colonoscopy Screening Coverage

120 months = 10 years

 

[James82]

I believe the issue is referred to as the "colonoscopy loophole" (see: The loophole is closing — Congress includes colonoscopy loophole bill in COVID-19 relief package). Essentially, the screening is covered per Medicare, however, if polyps are discovered during the screening, those costs, which are in the $200-300 range per polyp (see: Colonoscopy Without Insurance: How to Minimize the Cost and Where to Get Financial Help | Colonoscopy.com) aren't covered.

There's been recent changes to this billing, submitted as part of a Covid-19 relief bill, so we'd all be wise to keep an eye on whether that's passed and implemented, as this will almost certainly change in the coming months.

 

[somarco]

There's been recent changes to this billing, submitted as part of a Covid-19 relief bill, so we'd all be wise to keep an eye on whether that's passed and implemented, as this will almost certainly change in the coming months.

How will you advise your clients if/when this passes?