Researchers seek to stop surprise billing for colonoscopy

Nearly 1 in 8 commercially insured patients nationwide who underwent an elective colonoscopy between 2012 and 2017 performed by an in-network provider received "surprise" bills for out-of-network expenses, often totaling hundreds of dollars or more, new analysis from a team led by a UVA Health doctor shows.

James M. Scheiman, MD, chief of UVA's Division of Gastroenterology and Hepatology, has been deeply concerned that surprise billing may deter patients from getting recommended colonoscopies, increasing the chances that cancer and other digestive disorders remain undetected. So he and his collaborators set out to document the scope of the problem and develop potential solutions.

Colonoscopy is the most effective colorectal cancer prevention strategy in our medical toolbox. We cannot let out-of-pocket costs deter patients from undergoing this potentially lifesaving screening test."

James M. Scheiman, MD, Chief of UVA's Division of Gastroenterology and Hepatology

Colonoscopy insurance coverage

Scheiman and colleagues at the University of Michigan reviewed 1.1 million claims from a large national insurer for elective colonoscopies that were performed across the country between 2012 and 2017 where both the endoscopists and the hospital facilities were in-network. Of those, 12.1% involved out-of-network claims, with an average surprise bill of $418.

These bills often came because of the use of out-of-network anesthesiologists (64% of cases; median surprise bill of $488) and out-of-network pathologists (40% of cases; median surprise bill of $248). At UVA, colonoscopy anesthesia and pathology services are provided in-house, and there are no out-of-network costs for in-network patients.

"Particularly concerning was that 1 in 12 procedures that did not have an associated intervention had an out-of-network claim," the researchers write in a new Annals of Internal Medicine paper (link here). "This outcome is disconcerting since federal regulations eliminate consumer cost sharing for screening colonoscopy when performed in-network; and 2) a recent Federal Reserve Study reported that 40% of Americans do not have $400 to cover unexpected expenses."

Stopping surprise bills

The researchers go on to make important recommendations to spare patients surprise bills: Endoscopists and hospitals should partner with anesthesia and pathology providers who are in-network, and they should consider cost-saving strategies such as endoscopist-provided sedation rather than use of deeper anesthesia. Also, they say considerable healthcare dollars could be saved by adopting a strategy where not all low-risk polyps are sent for pathological evaluation. "In the longer term, we must enhance ongoing reform efforts to remove consumer cost sharing for all clinically indicated care associated with colonoscopy," the researchers write.

"In addition to insurance reform, which is essential to resolve this risk of cost sharing," Scheiman said,"we need tools to accurate predict out-of-pocket responsibilities for patients before the procedure is performed to allow opportunities to limit costs without impact on quality."

Findings published

The research team consisted of Scheiman, A. Mark Fendrick, Ushapoorna Nuliyalu, Andrew M. Ryan and Karan R. Chhabra. The team previously published a similar report on surprise billing for surgical procedures.

The research was supported by the University of Michigan's Division of Gastroenterology; the University of Michigan Institute for Healthcare Policy and Innovation's Policy Sprints Program; the Institute for Healthcare Policy and Innovation Clinician Scholars Program; and the National Institutes of Health's Division of Loan Repayment. A full list of the authors' disclosures is included in the paper.