Tom Contos is an avid runner. When he started experiencing rectal bleeding in March, he thought exercise could be the cause and tried to ignore it. But he became increasingly worried when the bleeding continued for weeks.<\/p>\n
The Chicago health care consultant contacted his physician at Northwestern Medicine, who referred him for a diagnostic colonoscopy, at least partly because Contos, 45, has a family history of colon issues.<\/p>\n
\u201cI work out a lot,\u201d he said. \u201cBut my partner said this isn\u2019t normal. My primary care physician said, \u2018Given your family history, let\u2019s get you in.\u2019\u201d<\/p>\n
Northwestern Memorial Hospital asked him to prepay $1,000 out-of-pocket, and he underwent the procedure in June.<\/p>\n
Then the bill came.<\/p>\n
The Medical Procedure<\/strong><\/p>\n Colonoscopies are performed in the United States more than 15 million times<\/a> a year. Rates of colorectal cancer are on the rise, particularly among younger people.<\/p>\n The procedure, which is also a recommended screening for people 45 or older, involves examining the large intestine using a tube with a video camera that can also collect tissue samples.<\/p>\n It typically takes less than one hour, with another hour spent taking the patient\u2019s history, administering anesthesia, and monitoring their recovery, said Glenn Littenberg, a physician who recently chaired the reimbursement committee of the American Society of Gastrointestinal Endoscopy.<\/p>\n According to Contos\u2019 medical record, the gastroenterologist who performed his colonoscopy described it as \u201cnot difficult.\u201d He biopsied and removed small growths called polyps from two spots and identified large internal hemorrhoids, which are swollen veins.<\/p>\n The biopsy samples were sent to pathology for testing and found to be precancerous. But the gastroenterologist reported finding no evidence of cancer, and after reviewing the pathology report, he concluded hemorrhoids were the likely cause of the bleeding.<\/p>\n The Final Bill<\/strong><\/p>\n 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 a patient share of $4,047. (It wasn\u2019t clear why the payments added up to slightly more than the negotiated price.) After Contos had paid $1,000 up front, plus $1,381 right after the procedure, the hospital said he still owed $1,666.<\/p>\n The Billing Problem: Colonoscopies That Find Polyps Cost More<\/strong><\/p>\n Contos was shocked and angry when he received his itemized bill. \u201cI said, \u2018I don\u2019t understand this.\u2019 Then I started to research the cost.\u201d<\/p>\n He asked the hospital what it charges for a diagnostic colonoscopy and was told he\u2019d been sent a cost estimate through his online patient portal prior to the procedure.<\/p>\n The estimate, which took his deductible of $3,200 into account, listed a total price of $7,203, with an out-of-pocket bill of $2,381. He asked Northwestern why the charges were nearly three times the estimate and why his out-of-pocket share was nearly twice as high.<\/p>\n One big reason was revealed in an explanation of benefits (EOB) statement from Contos\u2019 insurance company, Aetna: Northwestern had charged for two colonoscopies, at $5,466 each. And there were two fees for the gastroenterologist \u2014 $1,535 and $1,291.<\/p>\n The first procedure was listed as \u201ccolonoscopy and biopsy,\u201d while the second was listed as \u201ccolonoscopy w\/lesion removal.\u201d Aetna\u2019s negotiated member rate reduced the first $5,466 hospital charge to $3,425, while the charge for the second procedure was lowered to $1,787 \u2014 $1,638 less.<\/p>\n Neither the bill nor the EOB explained why there was a second procedure listed, at a reduced price.<\/p>\n After examining Contos\u2019 bill, Littenberg said it\u2019s standard for providers to bill for two colonoscopies if they remove two or more polyps in different ways, because of the extra work. As in this case, hospitals typically use a modifier code that reduces the amount charged for the second billed colonoscopy so they charge only for the extra work, he added.<\/p>\n \u201cHow do you explain that in sensible terms that anyone could understand?\u201d Littenberg said.<\/p>\n Even with that reduction, Littenberg said, he thought Contos\u2019 total out-of-pocket cost of $4,047 was \u201ca lot, though not rare for large academic centers.\u201d<\/p>\n Contos\u2019 insurance documents show Aetna\u2019s negotiated rate for his colonoscopy at Northwestern was more than twice the insurer\u2019s median negotiated rate for the same procedure at other Chicago-area hospitals, according to Forrest Xiao, director of quantitative research at Turquoise Health, a company that gathers health care price data.<\/p>\n In exchanges with Northwestern and Aetna representatives, Contos asked why he was charged for two colonoscopies. A Northwestern representative said that because of the modifier code, he wasn\u2019t actually being billed for two procedures, which Contos found bewildering.<\/p>\n \u201cI told Northwestern, \u2018I\u2019m not paying that, and I don\u2019t care if you send me to collections,\u2019\u201d he said. He filed appeals with the hospital and Aetna but was ultimately told the billing was correct.<\/p>\n The Resolution<\/strong><\/p>\n In an email, Contos told the billing department that its charge was \u201cridiculously high.\u201d A representative responded that Northwestern\u2019s pricing is in line with other academic medical centers in Chicago and \u201cnon-negotiable\u201d \u2014 and that his account would be turned over to a collections agency.<\/p>\n CVS Health spokesperson Phillip Blando said in a written statement to KFF Health News that the claims for Contos were \u201cpaid accurately\u201d by Aetna, declining further comment. (CVS Health owns Aetna.)<\/p>\n Northwestern did not respond to multiple requests for comment.<\/p>\n Contos said he wrote to his physician that he was regretfully dropping him and leaving Northwestern entirely because of the health system\u2019s high pricing.<\/p>\n He said he\u2019s still experiencing periodic symptoms, which he relieves with over-the-counter Preparation H. A one-ounce tube of the ointment costs $10.99 at CVS.<\/p>\n The Takeaway<\/strong><\/p>\n To get a colonoscopy at a lower price, Littenberg said, patients should consider going to a freestanding endoscopy center or ambulatory surgery center not associated with a hospital. A 2023 study<\/a> found that ambulatory surgery centers billed insurers an average of about $1,030 for a colonoscopy with biopsy or with removal of a polyp, compared with $1,760 at a hospital.<\/p>\n \t\t\t\t<\/a><\/p>\n \t\t\t\t\t\t\t\t\t\t\t\t\t\t\tA Toddler Got a Nasal Swab Test but Left Before Seeing a Doctor. The Bill Was $445.\t\t\t\t\t\t\t\t\t\t\t\t\t<\/p>\n \t\t\t\t\t\t\t\tNov 27, 2024\t\t\t\t\t\t\t<\/p>\n \t\t\t\t<\/p>\n \t\t\t\t<\/a><\/p>\n \t\t\t\t\t\t\t\t\t\t\t\t\t\t\tToddler\u2019s Backyard Snakebite Bills Totaled More Than a Quarter Million Dollars\t\t\t\t\t\t\t\t\t\t\t\t\t<\/p>\n \t\t\t\t\t\t\t\tOct 30, 2024\t\t\t\t\t\t\t<\/p>\n \t\t\t\t<\/p>\n \t\t\t\t<\/a><\/p>\n \t\t\t\t\t\t\t\t\t\t\t\t\t\t\tIn Chronic Pain, This Teenager \u2018Could Barely Do Anything.\u2019 Insurer Wouldn\u2019t Cover Surgery.\t\t\t\t\t\t\t\t\t\t\t\t\t<\/p>\n \t\t\t\t\t\t\t\tSep 25, 2024\t\t\t\t\t\t\t<\/p>\n \t\t\t\t<\/p>\n \t\t\t To get a sense of how much a diagnostic colonoscopy could cost, patients can consult a hospital\u2019s price website and an insurer\u2019s cost-estimator website, both required by federal price transparency rules.<\/p>\n Patients also can look up a good-faith estimate<\/a> of the cash price, which can be lower than the price for patients using insurance to pay for a procedure. In addition, they can check prices through websites such as Turquoise Health<\/a> and Fair Health<\/a>, which draw from federal price transparency data or claims data from insurers.<\/p>\n Still, the actual cost could be higher than the estimate if the colonoscopy finds one or more polyps that need to be removed and biopsied, which occurs in at least 40% of all colonoscopies, Littenberg said. Patients should ask whether the price includes those potentially extra services. After all, the point of a diagnostic colonoscopy is to find and, if necessary, treat lesions that could cause problems \u2014 regardless of the number found.<\/p>\n It all should be easier for patients, Xiao said: \u201cYou shouldn\u2019t have to be a medical billing expert to know what you\u2019re going to pay.\u201d<\/p>\n\n Bill of the Month is a crowdsourced investigation by KFF Health News<\/a> and The Washington Post\u2019s Well+Being<\/a> that dissects and explains medical bills.\u00a0Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it<\/a>!<\/em><\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\n\n\t\tBill of the Month\t<\/h4>\n
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