Explanation of Insurance Coverage for Colonoscopy

Insurance Coverage for Colonoscopy –Determining What You Might Owe

Essential facts: All insurance carriers have rules about your financial responsibility for a colonoscopy based on whether it is considered a “screening” or “diagnostic” procedure, and based on whether the physician finds anything during the procedure.

A “screening colonoscopy”  is a procedure performed on a patient with no current symptoms. Screening colonoscopies are considered either low/average risk or high risk depending on personal or family history of polyps or colon cancer. Some insurance companies pay 100% of all screening colonoscopies, regardless of risk.  Others will only pay 100% of the low/average risk screening colonoscopies.

A “diagnostic colonoscopy” is a colonoscopy that is performed in order to explain a patient’s current signs or symptoms, either as observed in the office or reported to the physician.

All colonoscopies are done to check for colon cancer or polyps.  If the physician  finds/removes a polyp or performs a biopsy during your procedure,  it may impact your financial responsibility, based on your insurance companies rules.  We are contractually and legally required to report any and all of our findings, as well as the initial reason for scheduling your procedure. We can not, therefore, schedule your colonoscopy as a “screening” simply to help you avoid paying deductibles, co-pays or co-insurance, nor can we fail to report any findings made during your colonoscopy.  To do so is considered fraudulent and could subject us to fines, penalties and loss of our contract(s).

We ask each patient to be responsible for knowing their carriers’ rules and to understand and respect our responsibility to code and report honestly.  We thank you for your understanding as we strive to provide you with the best care possible.