As responsible health care consumers, many of us know that getting our annual check-ups and other routine services is very important for our overall health. One of the most common routine tests for those 50 years old and above is the screening colonoscopy. In addition to this test being mandated at 100% coverage under the Affordable Care Act, for those of us residing in the State of Maine, there are extra measures put into place meant to save us out-of-pocket costs.
A few years ago, Maine adopted legislation that requires all colonoscopies booked as routine/screening, must be coded as routine/screening, regardless if a medical condition was found during the test. For example, if a member, aged 50, has their first screening colonoscopy, and a polyp is found during that test, the provider must still bill the procedure as routine/screening, and NOT with a medical diagnosis.
In addition, once a polyp is found, it must be sent to pathology to be tested. What many people do not realize is that that particular service must also be paid as a routine/screening procedure, in other words, at 100% coverage along with the rest of the exam.
Many times, the pathology claim will be sent to the insurance company separately than the colonoscopy claim itself. Oftentimes, it is from a totally separate provider from where the colonoscopy took place. Insurance companies don’t always automatically “tie” the two claims together, and may impose cost sharing such as deductible and/or coinsurance. If members receive a bill for pathology services related to a routine colonoscopy, they should call their insurance company right away and ask them to reprocess the claim as routine/screening and to be paid at 100%.