Mine are always covered. I’ve been on Medicare for 5yrs, they’ve covered 1 every year with no issues.

Mine are covered annually because I had dysplasia in my colon and have chronic inflammation in my pouch. Annual scopes are both indicated and covered by most insurance if you fall into either of those 2 risk categories. If you never had dysplasia or chronic inflammation it probably will not be covered nor should it be covered on an annual basis. It's also irrelevant if you are over 50, if you fall into one of those risk groups. I had them covered since age 29 for those reasons. You are either deemed in the risk groups or not, if not then it is NOT deemed preventative.

Mine are always covered, but never 100% with zero copay. That is because the “free” colonoscopies are for screening, not surveillance. My brother, who is over 65 did not get a free colonoscopy because he had a diagnosis of hemorrhoids, so it was follow-up, not screening.

They are always preventative, but not always routine screening.

So, when you say yours are not covered, are you saying you have to pay 100% out of pocket? If that is true, you are on the wrong plan.

Jan

I am nowhere near 50 but I would recommend talking to your doctor about it and seeing if maybe he can help you gt covered 100%. And maybe you can possibly talk to a supervisor of your insurance, I find that the supervisors often help the most when it comes to getting you covered in my experience. Hope this helps and Good luck

@CTBarrister posted:

Mine are covered annually because I had dysplasia in my colon and have chronic inflammation in my pouch. Annual scopes are both indicated and covered by most insurance if you fall into either of those 2 risk categories. If you never had dysplasia or chronic inflammation it probably will not be covered nor should it be covered on an annual basis. It's also irrelevant if you are over 50, if you fall into one of those risk groups. I had them covered since age 29 for those reasons. You are either deemed in the risk groups or not, if not then it is NOT deemed preventative.

I got my jpouch due to them finding low grade dysplasia in 2008, but I was told pouchoscopies are not covered

@Jan Dollar posted:

Mine are always covered, but never 100% with zero copay. That is because the “free” colonoscopies are for screening, not surveillance. My brother, who is over 65 did not get a free colonoscopy because he had a diagnosis of hemorrhoids, so it was follow-up, not screening.

They are always preventative, but not always routine screening.

So, when you say yours are not covered, are you saying you have to pay 100% out of pocket? If that is true, you are on the wrong plan.

Jan they are covered, but I have a very high out of pocket deductible. I have to pay like $4000 before it drops to 80/20 split. So unless I have a surgery or something big in the calendar year, I have to pay out of pocket which is about $1700.

Well, of course that is the pitfall of deductible plans. They get you one way or another. You either pay more in premiums or pay a high deductible. I crunched the numbers before we were on Medicare, and it turned out we paid the same out of pocket when compared to premium costs. But, when we chose a HDHP that was qualified for an HSA, we benefitted by being able to shelter savings and lower our taxable income.

But, we had to plan for a big cost early in the year. If you can’t do that, you are better off just paying the higher premiums for better coverage. My son just had a colonoscopy a week ago and they quoted his copay as $1700. His deductible is $1500 (low compared to many deductible plans).

Another option for you to consider is to discuss whether you really do need a scope as often. I have mine every 3 years now because all my biopsies have been negative for dysplasia. I only bring this up because your provider has no clue what your costs are or if it is a burden for you unless you tell him.

Jan

I pay as high a deductible as possible as Remicade takes out the deductible in one infusion and the Remistart payments count as out of pocket payments on most plans. So I pay lower premium payments (zero actually due to my firm's contribution) without the higher out of pocket costs. Being on Remicade is financially beneficial if one chooses a high deductible plan. This was the case under both my old plan with BCBS and my new plan with ConnectiCare which had $6500 and $5000 deductibles and my firm pays the premium cost up to $1000. No brainer!!!!!!! You get a windfall you do not really deserve, but I will take it.

Good point CT, but it only works if you are on a biologic with a copay assistance plan. Does not help for endoscopies.

Jan

I usually schedule my annual pouchoscopy in the summer and my deductible is long exhausted by then. There is a $60 copay, but the rest is covered as long as I use an in network doctor.

As Jan wrote, CT is describing a special case involving biologics + payment assistance in which the deductible is met without appreciable out of pocket expenditures. It has nothing to do with pouchoscopies, but in CT’s specific case the scheduling of procedures becomes significant.

@Jan Dollar posted:

Well, of course that is the pitfall of deductible plans. They get you one way or another. You either pay more in premiums or pay a high deductible. I crunched the numbers before we were on Medicare, and it turned out we paid the same out of pocket when compared to premium costs. But, when we chose a HDHP that was qualified for an HSA, we benefitted by being able to shelter savings and lower our taxable income.

But, we had to plan for a big cost early in the year. If you can’t do that, you are better off just paying the higher premiums for better coverage. My son just had a colonoscopy a week ago and they quoted his copay as $1700. His deductible is $1500 (low compared to many deductible plans).

Another option for you to consider is to discuss whether you really do need a scope as often. I have mine every 3 years now because all my biopsies have been negative for dysplasia. I only bring this up because your provider has no clue what your costs are or if it is a burden for you unless you tell him.

Jan

Yeah I have high premiums and high deductibles..lol. it sucks. when I had my first pouch done in 2008 it was mainly due to them finding low grade dysplasia. As you know I had a complete redo by Remzi in 2015. I have pretty much had a scope every year since then with biopsies and I have been clear. Dr Shen always stated it was important for me to get a scope every year due to the dysplasia, but Remzi told me a few years ago that if I wanted to skip a year it should be fine.. So I don't know, I think I am leaning towards doing the scope every other year with biopsies..  But back to my original question, how are some people getting theirs covered 100% and some aren't?

@Pouchomarx posted:

Yeah I have high premiums and high deductibles..lol. it sucks. when I had my first pouch done in 2008 it was mainly due to them finding low grade dysplasia. As you know I had a complete redo by Remzi in 2015. I have pretty much had a scope every year since then with biopsies and I have been clear. Dr Shen always stated it was important for me to get a scope every year due to the dysplasia, but Remzi told me a few years ago that if I wanted to skip a year it should be fine.. So I don't know, I think I am leaning towards doing the scope every other year with biopsies..  But back to my original question, how are some people getting theirs covered 100% and some aren't?

From everything you told me in the past, I think you should get pouchoscopys yearly.

Poucho, I believe some people were able to convince their insurance provider to cover their scope as a screening at one time or another, depending on their plan. But, more and more insurance providers are now holding the line in regard to how much of the cost they will cover if you are doing follow up procedures. Nowhere in any regular plan I know of does the plan pay 100% of the cost on an annual basis, especially if you have a known disease that is being monitored. Maybe if you had a platinum plan, but I don’t know about that either. Bottom line, insurance is not in the business of saving you money.

I still think you need to talk with your doc about it.

Jan

@Jan Dollar posted:

Poucho, I believe some people were able to convince their insurance provider to cover their scope as a screening at one time or another, depending on their plan. But, more and more insurance providers are now holding the line in regard to how much of the cost they will cover if you are doing follow up procedures. Nowhere in any regular plan I know of does the plan pay 100% of the cost on an annual basis, especially if you have a known disease that is being monitored. Maybe if you had a platinum plan, but I don’t know about that either. Bottom line, insurance is not in the business of saving you money.

I still think you need to talk with your doc about it.

Jan

I am just going to do my scope in office with my new surgeon without sedation. its about a fourth of the cost.

That seems like a great solution.

I have never used sedation and it is tolerable (not enjoyable, but tolerable). I like not needing a driver and being alert when the doctor talks about the findings. Plus, I like seeing for myself what is in there.

You can always step up the surveillance if things change.

Jan

Poucho,

Just to use real numbers, I think the retail cost of a pouchoscopy, at least in CT, is around $1000. I am guessing conscious sedation adds $150, Propofol adds $2000. Big difference there. So you need to elaborate when you say "sedation" exactly what sedation you are talking about. Because conscious sedation is cheap. Propofol is not. And this is a scam perpetrated by our healthcare system I have discussed many times in many threads.

CT, not sure what you are implying by saying this is a scam, but surely you must be aware that propofol is a general anesthesia medication and requires more careful monitoring than the usual conscious sedation. The medication cost does not determine the cost of a procedure, but the staff, facility and equipment does.

Sure, there may be some “upscaling” of procedures out there, particularly with PPO networks. Maybe that is a scam. I get my care through an HMO network, so everything is based on medically necessary and cost effective guidelines.

Jan

I am certainly well aware of that.  It's a scam because hospitals push a procedure that is 10 times more expensive on patients so they can do more procedures in one day and bill more to insurance companies and also give staff anesthesiologists something to do. Conscious sedation is 1/10th the cost and the patients are somewhat routinely (in larger medical centers and hospitals) not given that choice, unless they insist on it as I do.  That is the scam.  It is detrimental to the patient and it's a blatant and unethical violation of the Hippocratic Oath not to tell patients this.  But because more money is made by using propofol, they don't.  And it is financially detrimental to the patients because it is financially detrimental to their insurance companies.  This is common sense to anyone in the business (I work for insurance companies). I even confronted my GI about this and he admitted it and no longer even mentions propofol in my presence.

And I suspect Poucho, with his post above that I responded to, is one of the snookered who was also hoodwinked into thinking he must pay 4 times more or go without sedation.  But that is apparently his belief because he was only given a choice of propofol and did not ask about conscious sedation or its cost. I have seen these complete lies and fabrications regurgitated by patients elsewhere as well, because people are brainwashed to believe it is the truth when it is not the truth.  YOU HAVE A CHOICE, DON'T BELIEVE IT'S PROPOFOL OR PAIN BECAUSE THAT IS WHAT YOU ARE TOLD.

It's very similar to the large corporations buying up larger dental clinics.  If you are a patient at one of these facilities the dentists working for them are under pressure to upsell surgical procedures because that is what makes money.  Cleanings and fillings do not cut it.  For this reason my 83 year old father gets talked into having his wisdom teeth removed, wisdom teeth that were not hurting or bothering him in any way.  They told him his wisdom teeth were growing sideways and showed him some doctored x rays to frighten him into submitting into unnecessary surgery.  Everyone here has to be vigilant and be their own best advocate. Lots of unnecessary procedures are being sold to lots of people.  It's particularly easy to do to sick people, the elderly, the emotionally vulnerable, and those desperately looking for answers to complex medical issues.  This board's membership checks a lot of those categories.

They came and asked me if I wanted sedation. I spoke to my doctor, they had no problem with what I wanted to do. You need to speak up and ask questions and be able to trust your doctor.
Pouchoscopy’s are expensive, just like everything else.
mine from last September was $13,317. No sedation but if I did would’ve been $593.
Thank god for insurance my portion was only $185.

I do miss having it done in the doctors office, use to only cost me a co-payment.. those were the days!

OK, I get what you are talking about. I have had Kaiser, a non profit HMO that is also the provider, for over 50 years. The structure is similar to Cleveland and Mayo Clinics. Most everything is Kaiser supplied. Almost like the Army. So, my experience is vastly different than many others.

Jan

Jan, I have had varied experiences from small offices in New York City and Connecticut, to treating at large hospitals and endoscopy centers in both states.  The experience is very different depending on where you go, but the hospitals and large private endoscopy centers tend to have it as their protocol to simply tell patients that they can either have propofol or not, and not even mention conscious sedation.  Poucho's post and its suggestion that going without sedation was one quarter of the cost suggested to me propofol was being rammed down his throat.  My point was that conscious sedation is comparatively cheap.  I have seen it itemized as around $150 retail and it simply adds only an incremental cost.  Therefore, the Poucho post made no sense to me unless he was talking about the cost of Propofol.  I do not like hearing patients not being given this choice.  It upsets me, because I think it's unethical and as an insurance defense attorney I am no stranger to medical facilities using very unethical practices and procedures which prioritize profits over their own patient's rights.  I have had providers try to do this to me and overheard them do it to others and in a few threads on sedation during pouchoscopies, others have reported not being told conscious sedation was a choice.  These practices are most common at hospitals and large, for profit endoscopy centers.  My personal GI personally owns one of the latter and when I was initially his patient he attempted this approach with me and we had a brutally frank conversation (because I like and respect him, if I did not I would have walked out the door and gone to another doctor).  He listened to what I had to say and admitted that propofol was pushed and the reasons why.  I am one of the few patients at that facility that ever gets conscious sedation.

On a separate but related note, I defended a personal injury case a few years ago in which the plaintiff was an elderly gentleman and Connecticut/Florida snowbird who had treated at a pain management clinic in Florida while wintering there.  He ran up around a $15,000 bill, which I learned was outstanding despite the man having a Medicare plan.  Without ever telling this man or his attorney, they did not bill his Medicare plan, because "it was an auto accident case."  The man's attorney and I sent a joint letter to them telling they had no authority to withhold billing to Medicare, which they were not doing because the Medicare adjustments would have shrunk that bill down to size and they would only get paid maybe $1,000 or less on the 15K bill.  After getting our letter- in which I threatened to take a deposition of the Office Manager of the facility and implied I might do something with the transcript, like send it to the Florida Attorney General- they submitted their bill to Medicare. But it was then rejected by Medicare because it was untimely.  They were then forced to compromise their bill, very substantially, in order to avoid the threatened deposition. Because this issue arose during a mediation of the case, plaintiff's counsel (a good guy and good attorney) and I worked together and both signed that letter I drafted, because we had a joint interest in seeing that the bill was paid by insurance or compromised appropriately as part of the settlement we were negotiating.

An insurance defense attorney's job is to basically slap at the hands reaching inside his or her client's cookie jars, and make sure nobody takes more cookies than they are supposed to. However, many times, it's not just plaintiffs and their attorneys reaching far into the cookie jar. It's also the medical providers. And when I see that done at the expense of the patient, even if the patient is suing my client, I slap pretty hard at the reaching hand.

@CTBarrister It’s certainly true that propofol costs considerably more than conscious sedation, and that can influence what choices are offered or encouraged. It’s not true that these are equivalent experiences, though. Propofol tends to more completely wall off any awareness of the procedure, and the recovery from propofol tends to be very quick and complete (vs. a much slower recovery from conscious sedation). For something like screening colonoscopy propofol leaves people more likely to return for their next screening, and broad acceptance is the only way screening programs succeed. If any sedation at all is needed for pouchoscopy (which is brief and in most cases only mildly uncomfortable) the quick recovery advantage still applies to propofol.

When making an argument about sedation choices the question comes down to “is the propofol worth the additional money?” You appear to be arguing that it never is, but that really depends on the individual. Why not argue that *any* sedation is an unnecessary expense? When insurance companies make choices about health care they are strongly biased toward lower costs, just as providers may be biased toward higher costs. The provider, though, will also care about my experience, comfort, and well-being, at least if I’ve chosen a decent provider. In my experience the insurer tends to be indifferent to these things.

Scott, you are not factoring in the detrimental impact to the patient's insurance premiums. At the end of the year the payout number is all that matters to underwriters in making this determination. The insurer is NOT indifferent to raising premiums due to larger payouts. The patient should be given a choice of accepting one form of sedation or another is what I have argued, and not have propofol rammed down their throats. I just want the right to make a choice and Poucho should as well. We and his doctors should not be making the choice of propofol for him.

I think more people choosing propofol only increases healthcare insurance costs for everyone. You wonder why health insurance costs so much? This discussion illuminates one reason why.

@CTBarrister I agree that the higher cost has a real impact even if it’s not experienced out of pocket for the service. I also agree that informed patient choice would be best.

Without getting this thread further highjacked from the original question, I just need to point out that all of these variables surrounding invasive procedures and how to control the cost to patients are complex and not a given from one person to another. I have the same complaint about doctors who push brand name medications because they get kickbacks (not permitted at Kaiser) and patients wind up with higher copays, assuming they must have that fancy new drug.

Most of us are not lawyers or well versed in insurance litigation. So, it is helpful to know that there are numerous “moving parts” to every medical procedure, including coverage pitfalls. The main take away in my mind is that we need to COMMUNICATE with our providers. Physicians are pretty notorious for just being focused on their specialty and keeping their office running. They do not concern themselves with your costs or ability to pay them. That is, of course, unless you tell them there is a problem. Any good provider will work with you so you can get the care you need. If not, maybe they are not “all that.”

Jan

I’m so thankful I have 2 great doctors, gastro & pcp that are concerned for my health and the expense that it costs me.