Colorectal cancer rates for older adults in America have been dropping for decades. This may be because more people are getting screened and making healthy lifestyle choices, such as staying active, maintaining a healthy weight, and eating a diet low in animal fats and high in fruits and vegetables. However, colorectal cancer rates for people younger than age 50 are on the rise.
There’s no sure way to prevent cancer, but screening can find colorectal cancer early, when it’s small, before it spreads, and when treatment is more likely to succeed. Regular screening for people who have no symptoms of the disease is one of the most powerful preventive care benefits health plans offer.
Does insurance cover my colonoscopy?
Under the Affordable Care Act, private health insurers and Medicare cover the costs of all cancer screening tests recommended by the United States Preventive Services Task Force (USPSTF), a nonpartisan group of medical experts.
The USPSTF recommends regular colorectal cancer screenings for people with an average risk of the disease every 10 years, starting at age 45. Patients should have no out-of-pocket costs, co-pays, or deductibles for these screening tests.
If you have a family history of colorectal cancer or other risk factors, your doctor may recommend earlier screenings.
What happens during a colonoscopy?
A colonoscopy screening can help prevent colorectal cancer by finding polyps before they turn into cancer. During the procedure, the doctor examines the entire length of the colon and rectum with a colonoscope, a flexible tube with a light and small video camera on the end.
The type of doctor who performs colonoscopies is a gastroenterologist. If needed, the gastroenterologist can pass special instruments through the colonoscope to remove any suspicious polyps or take tissue samples. Before the procedure, an anesthesiologist delivers a sedative, so patients don’t feel a thing.
Abnormal cells that start to grow into polyps usually take about 10 to 15 years to develop into colorectal cancer. People with a history of benign (non-cancerous) polyps may need more frequent screenings because polyps can be a precursor to cancer.
Screening colonoscopy vs. diagnostic colonoscopy: What’s the difference?
Some colonoscopies are classified as preventive screening tests, while others are for diagnosis. The classification makes a difference for your out-of-pocket costs because patients don’t pay for preventive screenings under the Affordable Care Act. Diagnostic tests, on the other hand, can generate a bill.
Gastroenterologists perform both types of colonoscopies using the same equipment. The difference is how they bill the procedure to your insurance.
Knowing whether a procedure is considered a screening colonoscopy or diagnostic colonoscopy is not always simple. That’s why it’s important to understand your health insurance coverage before the procedure.
For example, if you take a stool-based test such as Cologuard and receive a positive result that requires a follow-up colonoscopy, the procedure is considered a screening test.
Always call your health plan before your colonoscopy appointment so you’ll understand what your out-of-pocket costs will be.
What is a screening colonoscopy?
A screening colonoscopy is a preventive test to detect abnormal growths or early signs of colorectal cancer. Gastroenterologists perform screening colonoscopies for patients who have no gastrointestinal issues or symptoms of colorectal cancer.
Most health plans cover the cost of a screening colonoscopy as long as you see an in-network provider. In certain situations, you may be charged for some services, so be sure to review the specific details of your health plan.
If you see a doctor who is not in your plan’s network, you may have to pay more out-of-pocket. Similarly, if a member of the healthcare team is out-of-network—for example, the anesthesiologist—this may also generate a bill.
On the other hand, if you’re under the age of 45 and have a high risk of colorectal cancer due to a personal history or family history of polyps, the procedure should be considered a screening test.
What is a diagnostic colonoscopy?
In some instances, a colonoscopy is considered to be a diagnostic test, rather than a screening test, which is subject to a deductible, copay, or coinsurance. A diagnostic colonoscopy is performed when a patient has specific symptoms, with the goal of diagnosing underlying conditions.
Symptoms that can lead to a diagnostic colonoscopy include:
- Unexplained abdominal pain
- Changes in bowel habits
- Unintentional weight loss
- Anemia from an unknown cause
- Constipation
- Diarrhea
- Rectal bleeding
- Blood in the stool
Gastroenterologist also perform diagnostic colonoscopies on patients with inflammatory bowel disease (IBD), a family history of colorectal cancer, or a personal history of colorectal polyps.
What happens if a polyp is removed during a colonoscopy?
Screening colonoscopies allow gastroenterologists to find and remove polyps from the colon and rectum. A pathologist examines the tissue to determine if it contains cancer.
It’s very common for gastroenterologists to find and remove polyps during a colonoscopy. Most polyps are benign or pre-cancerous.
When a doctor removes a polyp during the procedure, some insurance companies consider a colonoscopy to be a diagnostic test, rather than a screening test. However, according to the Centers for Medicare & Medicaid Services (CMS), under the preventive services provisions of the Affordable Care Act, the removal of a polyp during a screening colonoscopy is an integral part of the procedure, so patients should not receive a bill.
Before getting a cancer screening, it’s always a good idea to contact your health plan to find out if there are any coverage limitations or if you will be responsible for any out-of-pocket costs. Ask if this could change based on what the provider finds during the test.
Under the No Surprises Act, doctors and healthcare providers must give good faith estimates of your expected costs before a planned procedure.
Get your recommended colorectal cancer screenings
Colorectal cancer is one of the most common and deadly cancers. Getting screened according to USPSTF guidelines is one of the most effective ways to prevent it. The disease is much easier to treat when it’s caught early, so ask your doctor if you’re due for a screening colonoscopy.