I’m 27 and have had stomach issues for a few years. My primary care doctor referred me to a GI specialist, who recommended a colonoscopy. This week, I received a bill for $3,700. My in-network deductible is $5,000, with a max out-of-pocket of $6,000. My plan is only covering 30% of the total costs.
I realize now that I should have checked on coverage beforehand, but I’m worried. Since I’m young, the colonoscopy doesn’t count as preventative care. My PCP referred me due to concerns about my health, but TriHealth’s billing office told me that physician care and hospital procedures are treated separately, even though it was done by a specialist. They said the procedure was classified as “non-preventative hospital care,” so it wasn’t fully covered.
I asked for documentation to explain this, but they said they can only send me an itemized receipt in 7–14 business days.
I’m confused and a bit scared. I don’t understand how this works, and no one seems interested in helping me. It’s probably too late to change anything about the bill, but can someone explain what I did wrong and what I should have done differently?
Preventative care is exempt from out-of-pocket costs to encourage people without symptoms to get screenings. Since this was a diagnostic procedure, your regular plan rules apply. It looks like you have a high-deductible health plan, which allows you to set aside tax-free money in an HSA to cover these types of expenses. While that doesn’t help now, you should consider contributing to your HSA for future costs.
First, check if the bill matches your Explanation of Benefits (EOB). Then, call the hospital or doctor’s office to see if you qualify for any discounts based on your financial situation. If that doesn’t work, ask for a payment plan.
Avoid using a credit card for the balance, as most medical debt doesn’t accrue interest.
I have a few hundred in my HSA, but I haven’t been able to contribute as much as I’d like recently. I suspect I might earn too much to qualify for discounts, but a payment plan without interest would be ideal.
Be sure to ask the medical center about any discounts they may offer and set up a payment plan. The good thing about HSAs is that if your account was open when the medical expense happened, you can reimburse yourself later, even if you don’t have the funds right now. That can help save you some money. Just be sure to keep all your receipts in case of an audit.
I did the same thing after I had a big out-of-pocket expense from hospital and doctor bills due to some costly tests last year. I set up a payment plan with the providers and made monthly payments from my HSA while still adding to it with each paycheck. Even though I could have, I didn’t pay the full amount all at once.
Is it not covered or just applied to your deductible? Since your insurance paid something, I’m assuming it was applied to the deductible, and this is just part of your benefits.
Your procedure was labeled as “non-preventative hospital care,” which makes sense since it was likely diagnostic due to symptoms. Colonoscopies are typically done in a hospital setting, though not as inpatient care.
It’s always smart to call your insurance before a procedure to find out how it will be covered. The mistake you made was not checking your benefits, which led to the surprise bill.
You should ask the hospital if they offer any financial assistance.
This is my first time having a personal health plan, and it’s been a huge learning experience. Even with about $350 taken from my paycheck each month, a $5000 deductible, and a $6000 out-of-pocket maximum, I’m still surprised by how much I’m being billed for medical expenses.
The $5000 deductible means you need to pay that amount before your insurance starts covering most services, especially big ones like this. There are some helpful websites and YouTube videos that explain the basics of health insurance if you’re looking to learn more.
I’ve had bad gastritis since I was 20, so I know how expensive these procedures can get, especially now with high deductible plans everywhere. I hope you’ve paired your plan with an HSA to help cover some of the costs with pre-tax dollars. If not, try setting up a payment plan or negotiating a lower rate with the doctor’s office.
The same thing happened to my wife when she was younger, and I’ve experienced it too, though not as young. Once they suspect there’s an issue, the procedure isn’t considered preventative anymore. Unfortunately, there’s not much you can do but take it as a lesson to ask more questions next time. Still, the procedure was necessary regardless.
This is also why I recommend against choosing stool tests over a colonoscopy at the recommended age (like 45). If they find something in the stool test, you’ll still need a colonoscopy, and it won’t be considered preventative.