A Chicago-area man went to Northwestern Memorial Hospital for a diagnostic colonoscopy after experiencing a few months of rectal bleeding. His procedure was unremarkable.
According to Contos’ medical record, the gastroenterologist who performed his colonoscopy described it as “not difficult.” He biopsied and removed small growths called polyps from two spots and identified large internal hemorrhoids, which are swollen veins.The biopsy samples were sent to pathology for testing and found to be precancerous. But the gastroenterologist reported finding no evidence of cancer, and after reviewing the pathology report, he concluded hemorrhoids were the likely cause of the bleeding.
Then the bill arrived. It was $19,206, for two colonoscopies: a colonoscopy with biopsy and a colonoscopy w/ lesion removal. Basically, when the gastroenterologist had to remove polyps, the academic medical center billed it as two separate procedures. While it is not uncommon to charge extra for polyp removal, it is uncommon for it to be billed as an extra colonoscopy. It is also not uncommon for polyp removal to be included in the cost of a colonoscopy. I have seen cash prices for colonoscopies that include an unlimited number of polyps removed for less than $1,500.
To get a colonoscopy at a lower price, Littenberg said, patients should consider going to a freestanding endoscopy center or ambulatory surgery center not associated with a hospital. A 2023 study found that ambulatory surgery centers billed insurers an average of about $1,030 for a colonoscopy with biopsy or with removal of a polyp, compared with $1,760 at a hospital.
The No Surprises Act, a federal law that went into effect in January 2021, outlaws surprise medical bills of the type that occurred when patients were treated by an out-of-network physician at a facility in their health plan. Furthermore, in his first term President Trump issued an executive order requiring hospitals to post prices. The problem is that hospitals are finding new ways to spring surprise medical bills on patients. A few days ago I wrote about some new surprise medical bills, where physicians bill simple clinical procedures as surgeries costing hundreds of dollars.
Mr. Contos had gotten a good faith estimate of the cost prior to the care. What he didn’t realize was that: 1) you would never go to a hospital for care that can be performed elsewhere; and 2) that his good faith estimate was not provided in good faith. The hospital did not inform him that a poly would change the price by nearly double. Another fun fact: Had Mr. Contos gone to his doctor and just requested a colonoscopy due to his age and family history of colon cancer it would have been free. Going to his doctor and discussing blood in his stool changed the procedure from a preventive service (that has no cost sharing) to one that is diagnostic that has normal cost sharing. The two polyps were unrelated to his bloody stool but because the procedure was coded as diagnostic a second colonoscopy was added to his bill.
That million-dollar question is: what can be done about surprise medical bills like these? Real price transparency with actual estimates would have made a huge difference. How was a hospital able to code polyp removal as a second colonoscopy? Why was he not told that if he had polyps the cost would double? Why does a so-called good faith estimate become meaningless when a hospital wants to boost charges? For that matter, why do we allow hospitals to charge prices like $20,000 for a typical colonoscopy when the net price is far lower?
The No Surprises Act created a system of independent dispute resolution to mediate conflicts between doctors and health plans. It doesn’t work well. Panel members usually side with providers, often awarding rates far above median in-network rates. This suggests the independent board members have been captured by the industry they’re paid to regulate. A similar independent board for surprise medical bills that derive from upcoding and double coding would likely fare no better in mediating similar conflicts.
Read more at KFF: He Went in for a Colonoscopy. The Hospital Charged $19,000 for Two
This is a very important article.
I wrote a piece about three years ago advocating for specialized health courts, with the ability to impose fair prices.
I am not happy to say this, but price-gouging like this is the best argument for Medicare-for-All.
Either that, or a cheap way for a patient to contest what is done to them. I am open to any suggestions!
One tactic that might help is to enforce much stricter regulations on non-emergency transactions.
I am thinking of an approach that would say, in effect, “No provider disclosure = No patient liability.”
If the provider does not provide what their actual charge will be, the patient owes them NOTHING beyond the Medicare fee schedule.
Of course there would be an allowance for unforeseen complications….a very limited allowance.
The provider would have no appeal. They have burned their bridges with America too often!
A tactic that hospitals use to force patients to pay them and their doctors is a blanket financial responsibility form. How courts can claim that represents a meeting of the minds is hard to fathom. Your idea fits in nicely with contract law that usually requires mutual assent. Without a reasonable estimate there can be no mutual assent,