UnitedHealthcare will not pay for my colonoscopy!

So I am still in shock over this and am wondering if anyone else has come across this and want to warn you that you may. I had my 1st colonoscopy in January 2008 and had my second one in October (last month) since I am consider "high risk" due to UC. This month is suppose to be my last month I am able to get COBRA. I sucked it up and payed the 500. for the COBRA last month so I could stock up on meds and have my colonoscopy. I looks like that was my last month of health insurance as the 500. I considered paying this month (to stock up on meds) will need to go towards the 900. I am being charged for my colonoscopy.

Here is the low down. Supposedly this is part of the new healthcare laws. Anyway, because I have been diagnosed with UC my scope is not considered "preventative" but rather "diagnostic" and therefore not covered. I spoke to the person in charge of billing and codes both yesterday and today and can not wrap my head around it. I am allowed to have my once every 10 year screening and have that covered. I even asked, "so I am suppose to wait 10 years, be diagnosed with stage 4 colon cancer, and then they will pay for that?" It makes no sense. I even researched online. My Policy is United HealthCare ChoicePlus and is through a college for it's faculty. It is a great policy, or so I thought. This is what I found and the link to the site of United Healthcare's Guidelines for Preventative services. I apologize for this being so long but I feel it is important information for others:

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Preventive_Care_Services_CD.pdf


Preventive vs. Diagnostic Services:
Certain services can be done for preventive or diagnostic reasons. When a service is performed for the purpose of preventive screening and is appropriately reported, it will be adjudicated under the Preventive Care Services benefit.
Preventive services are those performed on a person who:
1. has not had the preventive screening done before and does not have symptoms or other
abnormal studies suggesting abnormalities; or
2. has had screening done within the recommended interval with the findings considered
normal; or Preventive Care Services
3. has had diagnostic services results that were normal after which the physician recommendation would be for future preventive screening studies using the preventive services intervals.
4. has a preventive service done that results in a therapeutic service done at the same encounter and as an integral part of the preventive service (e.g. polyp removal during a preventive colonoscopy), the therapeutic service would still be considered a preventive service.

Examples include, but are not limited to:
 A woman had an abnormal finding on a preventive screening mammography and the
follow up study was found to be normal, and the patient was returned to normal mammography screening protocol, then future mammography would be considered preventive.
 If a polyp is encountered during preventive screening colonoscopy, the colonoscopy, removal of the polyp, and associated facility, lab and anesthesia fees done at the same encounter are covered under the Preventive Care Services benefit.
When a service is done for diagnostic purposes it will be adjudicated under the applicable non- preventive medical benefit.

Diagnostic services are done on a person who:
1. had abnormalities found on previous preventive or diagnostic studies that require further
diagnostic studies; or
2. had abnormalities found on previous preventive or diagnostic studies that would recommend a repeat of the same studies within shortened time intervals from the recommended preventive screening time intervals; or
3. had a symptom(s) that required further diagnosis.

Examples include, but are not limited to:
 A patient had a polyp found and removed at a prior preventive screening colonoscopy.
All future colonoscopies are considered diagnostic because the time intervals between
future colonoscopies would be shortened.
 A patient had an elevated cholesterol on prior preventive screening. Once the diagnosis
has been made, further testing is considered diagnostic rather than preventive. This is
true whether or not the patient is receiving treatment.

If a Preventive service results in a therapeutic service at a later point in time, the
Preventive Service would be adjudicated under the Preventive Care Services benefit and the therapeutic service would be adjudicated under the applicable non-preventive medical benefit.

Related Services:
Services that are directly related to the performance of a preventive service are adjudicated under the Preventive Care Services benefit. For example, all services for a preventive colonoscopy (e.g. associated facility, anesthesia, pathologist, and physician fees) are adjudicated under the Preventive Care Services benefit. Note, however, that benefit adjudication is contingent upon accurate claims submission by the provider, including diagnosis, procedure, age and gender.

Post Edited (beeswax) : 11/8/2011 4:19:48 PM (GMT-7)

I am so sorry you are going through this. This is one of those things that gets us so angry at these companies as they are just looking for any reason not to cover you. Is there any way that your Dr's office can recode it in a way that they would be willing to pay for it. I bet the Dr. has someone in their office that deals w/ the codes and insurance companies and maybe can help you.

If not and you exhausted all health insurance avenues...try to negotiate payment w/ the Dr. and Colonoscopy place. Sometimes they will work out a payment plan where you can pay monthly or possible give you a reduced rate if you can pay in a one lump sum. Pls keep us posted and I wonder what other creative ideas some other people will have with this.

Thanks pmedic and hateuc, I have spoken twice to the person who does the codes and she is the one who explained it to me. I can work out a payment system but have not called about that yet. I was just so upset. I was on the verge of crying after my two conversations but had to go to work so I held it together. If I had known it would cost so much I would not have had it done. I would hold out and hope I had a full-time job with benefits in the next year or two. It is just disheartening. I was trying to be proactive. Knowing my GI he would have probably not encouraged me to do it, knowing my financial situation. Many times he does not charge the Specialist co-pay of 60. because he knows I have been unemployed/underemployed. I am considering writing him a letter so he is at least aware of it. I would schedule an appointment with him to talk about it but now I don't have any health insurance, unless I pay the 500. for COBRA. I need that money for my scope. Ahhh... Usually if you call you only get to talk to the nurse. I also am not sure there is much he can do about it. I had a 65% government subsidy towards my COBRA for 15 months; it is only the last couple of months it has been so high. Depressing:(

Have a look at the above Website; the woman who runs this organization is a lawyer with Crohn's & understands the semantic distinctions in these insurance policies. In some situations she can give specific advice to patients, including the unemployed, etc. / Old Hat (30 yrs with left-sided UC; presently in remission taking brandname Colazal)

I think the example about the polyp pretty much nixes any sort of recoding solution. The UC is like the polyp. Now any scoping less than 10 years - even if it is to screen for colon cancer and UC is in remission, would be diagnostic.

It does suck. If the 2nd scoping is to check on the UC, it should be regular, but if the scoping is to screen for cancer it should be "preventative" even if the closer screening interval is now recommended because of UC.

But if I understand they are not refusing to cover the procedure, but rather subject it to deductibles and co-insurance like most other procedures because it no longer qualifies for the 100% covered "preventative" discount many companies give.

It does suck, and doubly so that you got caught by surprise after paying for COBRA coverage. But I think we should be glad that most companies do provide 100% coverage for preventative services. I think some respondents are confusing "not covered" and "not covered 100% as preventative".

Or do I misunderstand and they will not provide ANY coverage of the procedure? $900 did seem cheap so I assume it was a 25-35% co-insurance, possibly with some additional for deductible.

I had no trouble with my 2nd scoping (1st Jan 2010, 2nd May 2011), and I hope it stays that way! I expected to pay a co-insurance on the 2nd one, but it went through at 100%. I think the doc coded it as screening for cancer, which allowed it to be preventative - but my BC/BS policy does not have the very specific definitions UnitedHealthcares seems to have.

My policy reads that anything coded as preventative is preventative - not all this stuff about what prior results showed. There is even a footnote that multiple colonoscopies a year are covered if they are all for screening, which is kind of hard to imagine how they could be.

I guess I will find out when I get a 3rd one, and I will try to set aside enough for the co-insurance just in case.

Here are my charges. The first number is the charge (left). The second is towards the "deductible", the 3rd is what is payed to the physician/etc. and the final is what I am responsible for, basically the deductible. Typically preventative care is 100% covered. There is no deductible.

Date of Service: 10/17/2011
More Details Processed
10/25/2011 $803.00 $500.00 $0.00 $500.00
Date of Service: 10/17/2011
More Details Processed
10/22/2011 $699.00 $402.97 $0.00 $402.97
Date of Service: 10/17/2011
More Details Processed
10/22/2011 $860.00 $0.00 $134.52 $0.00

Post Edited (beeswax) : 11/9/2011 6:13:11 AM (GMT-7)

I was diagnosed with Ulcerative Proctitis in 1993, which is why my primary doctor recommended a colonoscopy when I was 48, in 07/08. If I had been seeing that primary doctor earlier he may have recommended I have the first one even earlier. I have gone without health insurance for most of my adult life. My GI said he follows the Mayo Clinic's guideline for screenings when I met with him and he scheduled the one I just had. When I had my follow-up call after biopsies I was told I should have one again in 3 years. I think once you are 50 you should have screenings every 10 years, UC or not.

Post Edited (beeswax) : 11/9/2011 6:42:14 AM (GMT-7)

The only thing health reform did in regard to this is require that preventive colonscopies do not have copays.

Even if you were lucky enough to already have insurance that did not have copays for preventive colonoscopies, diagnostic colonoscopies for UCers still were subject to copays. That's always been my experience. I always use up my deductible and out of pocket max, so didn't matter much! An HMO was the best...

So don't blame it on health reform, it actually improved the situation for many.
The insurance companies design policies that way, it is your employer that accepted the terms. Lots of blame to go around, but it's not because of health reform.

Your state probably has some kind of high risk pool, see if it is structured in a way that can help you. But it's not free...

I am super excited for the US to get healthcare! We are one of the only developed countries that doesnt have it, it's crazy.

That being said, my insurance never paid for all of my scopes, in all the time i had UC. I always had to pay the copay on it. It may be possible to have your doctor talk with them to prove it was medically necessary to prevent further damage to your colon, or show them some research that shows how much more likely you are to get colon cancer. I say that because years ago,, when i still had UC, i went to some dr because i couldnt get my anemia under control and he prescribed some kind of medicine, chromagen, that wasn't covered by anything, it was considered a vitamin and not necessary. But my dr called and told them that if i didn't take the medicine i would be having blood transfusions every month or so. They then decided it would be in their best interest to pay for the medicine.
I don't know if the dr calling them and saying if you don't pay for scopes, then their will probably be hospital bills for damage and extreme illness.
where are you in NC? I'm near Hickory, which unless you live there you've probably never heard of, lol.
good luck!

My policy with BCBS AZ is written the same way. Colonscopies and a bunch of other tests are covered under preventive services free of deductable but once you have a diagnosed condition or symptoms it is not covered until you reach the deductible.Thing is that it is not really clear if a diagnosis of UC means anything in regard to cancer screening. My policy has no frequency limitations on colonscopies. Many peoples bills get paid.Mine did. The doctors office told me ahead of time it might not. BCBS fought me on screening blood tests claiming they were UC related when they were not because it was not an independent lab. I took it to the insurance commission and won. The coding by the doctors office is everything. Wrong code and charged as diagnostic not screening.

This has nothing to do with the health law. It has been going on for years. Obamacare is just this decades excuse for everything.

I refuse to get colonscopies at this point because I can't afford it and am afraid the insurance won't pay.

Will they change that kind of stuff next year? I mean sure the insurances cannot deny us anymore for our pre-existing condition. But how much will they cover in 2014??

Oh, they can still deny us for our pre-existing conditions. Happened to me a couple months ago. Leave it to a politician to word is just so you fall for the line... The truth is, if you're looking for an individual policy, we can be denied as long as there is another insurance option available (ex. a public high-risk insurace policy that charges through the roof).