Tom Contos is an avid runner. When he started experiencing rectal bleeding in March, he thought exercise might be the cause and tried to ignore it. But as the bleeding continued for weeks, he became increasingly concerned.
The Chicago healthcare consultant contacted his doctor at Northwestern Medicine, who recommended he undergo a diagnostic colonoscopy, in part because the 45-year-old Contos had a family history of colon problems.
“I exercise regularly,” he said. “But my partner said this wasn’t normal. My primary care doctor said, ‘Given your family history, let’s get you in.'”
Northwestern Memorial Hospital required him to pay $1,000 upfront out of pocket, and he underwent surgery in June.
Then the bill came.
medical procedure
More than 15 million colonoscopies are performed each year in the United States. The incidence of colorectal cancer is increasing, especially among younger people.
The procedure, also a recommended screening test for people aged 45 or older, involves examining the large intestine using a tube with a camera that also collects tissue samples.
It typically takes less than an hour, plus an additional hour to take the patient’s history, administer anesthesia and monitor his recovery status.
According to Contos’ medical records, the gastroenterologist who performed the colonoscopy described it as “not difficult.” He biopsied two spots and removed small growths called polyps and discovered large internal hemorrhoids, which are swollen veins.
The biopsy sample was sent for pathology testing and was found to be precancerous. But the gastroenterologist reported finding no evidence of cancer, and after reviewing the pathology report, he concluded that hemorrhoids were the likely cause of the bleeding.
final bill
The hospital billed a total of $19,206 for the procedure, including physician fees. The insurance company negotiated the price to $5,816 and paid $1,979, leaving the patient’s share of $4,047. (It’s unclear why the payments added up to slightly more than the negotiated price.) After Contos paid $1,000 up front, plus $1,381 immediately after the surgery, the hospital said he still owed $1,666.
Billing Issues: Colonoscopies that reveal polyps cost more
When Kontos received the detailed bill, he was shocked and angry. “I said, ‘I don’t understand this.’ Then I started looking at the costs.
He asked the hospital how much a diagnostic colonoscopy would cost and was told that he had received a cost estimate through an online patient portal before the procedure.
The estimate takes into account a $3,200 deductible and lists the total price at $7,203, with out-of-pocket expenses of $2,381. He asked Northwest why it was being charged nearly three times the estimate and why his out-of-pocket costs were nearly twice the estimate.
An explanation of benefits (EOB) statement from Contos’ insurance company Aetna revealed a big reason: Northwestern charged $5,466 for two colonoscopies. There are two fees for a gastroenterologist: $1,535 and $1,291.
The first procedure was listed as “colonoscopy and biopsy,” while the second procedure was listed as “colonoscopy and removal of lesions.” Aetna negotiated membership rates that lowered the first $5,466 hospital stay to $3,425 and the second surgery to $1,787, a $1,638 reduction.
Neither the bill nor the EOB explains why the second procedure is listed at a lower price.
After reviewing Contos’ bill, Littenberg said it’s standard practice for providers to pay for two colonoscopies because of the extra work required if they remove two or more polyps in different ways. He added that in such cases, hospitals often use modification codes to reduce the amount charged for the second colonoscopy, so they only charge for the additional work.
“How do you explain this in reasonable language that anyone can understand?” Littenberg said.
Littenberg said that even with this reduction, he believes Contos’ total out-of-pocket costs would be $4,047, “which, while not unusual for a large academic center, is still significant.”
Forrest Shaw, director of quantitative research at Turquoise Health, said Contos’ insurance documents show Aetna’s negotiated rates for colonoscopies at Northwestern are higher than what insurers charge for other Chicago-area hospitals. More than twice the median negotiated rate for the same procedure.
In exchanges with Northwestern and Aetna representatives, Contos asked why he was charged with having two colonoscopies. A representative from Northwestern said Contos was confused that he had not actually been paid for the two surgeries because of the revised code.
“I told Northwestern, ‘I’m not going to pay, I don’t care if you send me to collect,'” he said. He appealed to the hospital and Aetna, but was ultimately told the bill was correct.
resolution
Contos told the billing department in an email that its charges were “ridiculously high.” A representative responded that Northwestern’s pricing was in line with other Chicago academic medical centers and “non-negotiable,” and that his account would be turned over to a collection agency.
CVS Health spokesman Phillip Blando said in a written statement to KFF Health News that Aetna has “accurately paid” Contos’ claim, but declined further comment. (CVS Health owns Aetna.)
Northwestern University did not respond to repeated requests for comment.
Kontos said he wrote to his doctor who regretfully gave up on him and left Northwestern solely because of the high charges in the medical system.
He said he still has periodic symptoms that are relieved by over-the-counter Preparation H.
takeout
To get a lower-priced colonoscopy, Littenberg said, patients should consider going to a freestanding endoscopy center or an ambulatory surgery center not affiliated with a hospital. A 2023 study found that outpatient surgery centers charged insurance companies an average of about $1,030 for a colonoscopy biopsy or polyp removal, compared with $1,760 for hospitals.
This month’s bill
More from the series
To find out how much a diagnostic colonoscopy costs, patients can check the hospital’s pricing website and the insurance company’s cost estimate website, both of which are required by federal price transparency rules.
Patients can also check for true estimates of cash prices, which may be lower than those for patients who use insurance to pay for the procedure. In addition, they can check prices through websites such as Turquoise Health and Fair Health, which draw from federal price transparency data or insurance company claims data.
Still, if the colonoscopy reveals one or more polyps that require removal and biopsy (which occurs in at least 40 percent of colonoscopies), the actual cost may be higher than estimated, Littenberg said. Patients should ask whether the price includes those potential additional services. After all, the purpose of a diagnostic colonoscopy is to find and, if necessary, treat lesions that may be causing problems—no matter how many are found.
Shaw said this should be easier for patients: “You don’t have to be a medical billing expert to know what you’re going to pay.”
Billing This Month is a crowdsourced survey by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers reduce their medical bills and has been cited in state capitols, the U.S. Capitol, and the White House. Do you have a confusing or overwhelming medical bill you’d like to share? Tell us!
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This article first appeared on KFF Health News and is republished here under a Creative Commons license.
