Colonoscopy Controversy Continued

I blogged and did an Authentic Medicine Moment Video on the subject of insurance companies not paying for screening colonoscopies if a polyp is removed. Hit the link to review.  I received this email from an insurance manager who allowed me to share it with you.  My response follows but I would love your thoughts on this subject as well.


Dr. Farrago,

I usually agree with you, but today I have to say I do not agree with your take on calling the insurance companies “scam” companies regarding colonoscopies.  You are correct that healthcare reform requires preventive colonoscopies to be paid at 100%.  And you are correct that if a polyp is removed it becomes diagnostic and is not paid at 100%. However, the issue is not the insurance company.  The issue is the procedure code.  The procedure codes need to be updated.

These colonoscopy claims are automated claims.  A computer either sees the code for a preventive colonoscopy or it sees the code for a diagnostic colonoscopy.  The computer has now way of knowing that a preventive colonoscopy turned into a diagnostic colonoscopy.  The gastroenterologist’office staff simply codes the procedure as whatever it turned out to be and submits to the insurance company.

There is no claims person at the insurance company gleefully adjudicating the claim as diagnostic so that someone has to pay a deductible.

This is a simple problem with a simple fix.  This is not an insurance company generated problem nor is it something that they can fix.  It all turns on the procedure codes and how they are used.

I am an insurance agent and this is ONE of the things I discuss in EVERY enrollment meeting.  The mammogram is the other one.  If it is a screening mammogram it is paid at 100% however if the doctor suspects something it is not.  I warn all of my insureds about these pitfalls that healthcare reform has created.

There are many more pitfalls, not the least of which are higher premiums and the inability to sell individual policies to children in my statethanks to “Obamacare”.

Thank you for everything you do!



Thank you for sharing your thoughts.  You do make some great points but there is a bigger picture here.   I understand how the procedure codes are “computerized” but I truly believe that some higher ups in your industry knew that this would happen.  And I agree, the grunts at your company (and I am a grunt in my industry so that is not a knock) are the not the bad people and are not gleefully making people pay a deductible.  It may be that the damn specialists at the AMA deemed this procedure code necessary to get paid more and now it has turned even worse for the patients.  It doesn’t matter. If we want to blame your “higher ups” or my “higher ups” then that is fine.

 Let’s work backwards.  I believe in screening colonoscopies.  I agree that they should be covered.  I believe that the polyps need to be removed if they are there.  If they are, there should be some small fee added to the procedure that can be passed on to the patient.  Not the whole thing.

 It shouldn’t be rocket science for some computer geek to change the diagnostic procedure code to something else when it started as a screening procedure so that is triggers that small extra fee.

 Sharon, I would like this conversation to be on the blog so smarter people than me could discuss their points of view.  Would that be okay?




Yes, please post on the blog.  I agree that the specialists want to be paid more if a polyp is removed and rightfully so.  I think your solution is perfect.  The problem is that it is too simple and too logical.



Please tell me what you think is the best way to fix this debacle.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  4 comments for “Colonoscopy Controversy Continued

  1. Bridget Reidy MD
    February 3, 2012 at 6:08 pm

    And whatever you do don’t advise your patients to get their stool tested for blood. It will turn their nearly inevitable Colonoscopy into a purely diagnositic test.

  2. Bridget Reidy MD
    February 3, 2012 at 6:04 pm

    I love the way the insurance industry blames the billers for not knowing everything. What gave them the right to make it so complicated in the first place? Why did I need to pay 10% of my gross (about 20% of net) for a biller? (And I’m sure it’s only gotten worse because even with that situation five years ago it was hard to find a free lance biller with any work ethic, and complexity is increasing exponentially as we speak.)

    Complexity in the non medical part of medical care is the main reason for increased costs, and increased bureaucrats who don’t do anything useful. Remember when $30.00 copays were first introduced after insurance companies had gotten control of everything? It wasn’t that many noninflationary years earlier that doctor visits only cost $30.00!

    Granted the fact that it’s a screening Colonoscopy and a diagnostic Polypectomy isn’t that hard, but billers loose sight of meaningful concepts like that because of all the other trivia they need to know. I honestly don’t see how ICD 10 can work when most people still don’t code non-insulin dependent diabetes (250.00 only if controlled and no complications, even if taking insulin) and essential hypertension (401.1, not 401.9 except perhaps for the first week or so before the work up is done) correctly.

  3. DefendUSA
    January 17, 2012 at 7:23 pm

    Well, I learned something today. I ended up paying alot of money for a mammogram because of the very thing described. I realized too late that this was wrong and didn’t get reimbursed. There is a timeline for submissions of revisions to the reimbursing for services. Bummer.

  4. Stephen Rockower, MD
    January 15, 2012 at 9:47 pm

    And it will only get worse under ICD-10!!! As an orthopaedist, I don’t know how many codes there are now for colonoscopies, but if it is anything like arthroscopy, there will be 20 or 30 choices. Right colon or left colon? Left handed colonoscope? It will all go downhill from here….

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