Her colonoscopy should cost her $0 per federal law. Why was she asked to pay $765?

This story was updated on Feb. 15 at 11:43 a.m.

Karen Campbell teaches a Zumba dance class when she’s off her day job as a local television reporter. She loves to move and takes care of her health. So, when the 46-year-old received a letter from her doctor that she was due for a colonoscopy, she booked her appointment right away at Eskenazi Health in Indianapolis, Ind.

People between 45 and 75 should get a colonoscopy every 10 years, according to federal health guidance. This routine screening involves a small camera that goes through the rectum to search the intestine for abnormal growths like tumors or polyps as well as inflammation, bleeding or ulcers. Research suggests that the procedure slashes the risk of dying from colorectal cancer by more than 80%.

“I'm lying, you know, in the bed, and they're like counting down from 10. Next thing you know, you're knocked out. You wake up and you're like, ‘Oh, wow, that's it,’” Campbell recalled.

The doctor said her results came back clear. Campbell thought the most uncomfortable part was over.

Then, came the bill.

Campbell was slammed with $765 she had to pay out-of-pocket. She was shocked because preventative screenings –– including colonoscopies, mammograms and cervical cancer checks –– should not cost patients a dime, according to the Affordable Care Act

Anna Schwamlein Howard, policy principal at the American Cancer Society’s Cancer Action Network, said the ACA rules aim to improve access to preventative services for people in the U.S., where many patients skip or delay care for fear of medical charges.

“We want to encourage people to take advantage of evidence-based preventive services to keep people healthy for as long as possible [and] to detect diseases like cancer early,” Howard said. “One way that you want to encourage people… is you want to remove as many barriers as possible.”

But barriers are all Campell has been facing since she had the colonoscopy.

She is on an employer-sponsored private insurance plan –– BlueCross BlueShield of Texas. Eskenazi Health billed her insurance $6,732 for the service. BCBS negotiated the price down by more than half and then paid most of it, but left Campbell on the hook for $765.

Campbell did not pay the bill. And for a year and a half, she tried to figure out why she owes this money. She was given few answers and a lot of finger-pointing.

“Oh my God, calls, texts, emails –– I can’t put a number on it,” she said.

Federal law says it’s the responsibility of the insurance company — not the health care provider — to ensure that preventative care like Campbell’s colonoscopy is totally free for the patient. This loophole leaves providers with a chance to tack on other charges and let the insurer decide whether to cover the cost or pass it on to the patient.
 

Here’s how Campbell’s case played out.

Eskenazi Health did use the correct medical billing codes. And Campbell’s insurance fully covered the screening colonoscopy procedure itself. But it didn’t fully cover another big hospital charge of $2,888 for a “recovery room.” That’s where staff monitored Campbell as she woke up from the anesthesia –– and where most of the $765 Campbell owes came from.

If Campbell’s colonoscopy was done at a doctor’s office, there wouldn’t have been this recovery room charge, said John Hargraves, director of data strategy at the Health Care Cost Institute, a nonprofit that tracks health care spending and medical charges. According to Hargraves, getting some procedures done at a hospital –– as opposed to a surgical center or a clinic –– can actually cost patients more.

“A recovery room, as a billable service, does not exist in a doctor’s office. It’s only in facilities [like hospitals],” he said.

Eskenazi Health stands by their handling of Campbell’s medical bill. They said doctors and nurses continuously monitor patients in the recovery room as they wake up from anesthesia for any problems like breathing or heart issues. There’s staff on standby and medical resources ready to go in case of any complications, said Nicole Harper, Eskenazi Health’s chief financial officer.

Harper also said the hospital bills for a recovery room charge with screening colonoscopies all the time and hasn’t run into issues with insurance before. She said cases like Campbell’s really concern her.

“We can't heal patients clinically and then make them ill financially,” she said. “Patient care actually extends through the billing portion of a patient's experience in my world, from my point of view.”
 

A game of Whac-A-Mole

Guidance from the Centers of Medicaid and Medicare Services says not only should there be zero patient cost-sharing for the screening colonoscopy itself, but also for any services that are necessary to perform the procedure. This includes anesthesia, but it’s unclear if a “recovery room” is part of that.

“Whether the fees associated with recovery room usage are permitted to be charged would depend upon whether recovery room usage is an integral part of performing the colonoscopy,” a statement by a CMS representative said.

Physicians and patient advocates argue that a recovery room should in fact be part and parcel of a colonoscopy. For some patients, the procedure is unpleasant at best, and they choose to undergo the colonoscopy under anesthesia. So, it stands to reason that a recovery room can be an integral part of the procedure, said Shelley Safian, a medical coding and billing expert and an advocate who helps patients dispute medical charges.

“The procedure is done. You will leave the procedure room, and you're just gonna walk away and say [to the patient], ‘Okay your car is in the parking lot, or you can get an Uber at the front door’?” Safian said. “What do you think would happen if you didn't monitor a patient who was under anesthesia? Bad things could happen, and lawyers get rich.”

Per state and federal law, Eskenazi Health did not violate any CMS provisions.

But researchers say it’s like a game of Whac-A-Mole. Health care providers want to maximize their revenue and charge for every service that goes along with the colonoscopy, while insurers and health plans want to pay for as little as possible, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University’s McCourt School of Public Policy.

For the past decade, CMS has been trying to stamp out some of the egregious practices by providers, while ensuring insurance companies and health plans do not pass on any costs to the patients, she said.

“Absent a very clear directive from the federal government that the [insurer] has to pay for every single charge on that bill, every time somebody has a screening colonoscopy, I think these problems are going to continue to crop up for patients,” Corlette said. “So, I think because CMS has not spoken to this specific circumstance yet, the patient is left with the provider and the payer pointing their fingers at each other.”

Campbell stood her ground and didn’t pay the charge. The hospital eventually sent her bill to debt collectors, who hounded her for the money.

“They leave texts and call as many as five times a day every day,” Campbell said.

Less than 48 hours after Side Effects contacted the hospital about Campbell’s situation, a director there informed her that they took her bill off debt collections. They also contacted the insurance company to appeal and asked why Campbell’s bill wasn’t fully covered. This time, — more than a year and a half after Campbell started asking questions — insurance covered it all.

BCBS declined to discuss Campbell’s case with Side Effects despite a written authorization from her. But the insurer told Campbell they had a “processing error” in the claim and finally fixed it.

It’s hard to know how many other patients may have been in a similar situation.

Advocates worry that patients don’t know how to dispute medical bills. So, they’ll either just pay and struggle — or they won’t, and that medical debt becomes another anchor rooting them deeper into poverty.

“It does worry me a little bit for the future. My husband is due for a colonoscopy and because of this, he doesn't want to get one done because he doesn't want a bill,” Campbell said. “So it comes down to your wallet over your health.”

Howard of the Cancer Action Network advises patients to dispute medical charges when necessary, but, more importantly, to never put off preventive care for fear of medical bills. She said prevention can save patients a lot more money and ward off potentially devastating health problems if, down the line, they develop cancer that’s not diagnosed early enough.

CORRECTION: The story previously stated that the patient is on an Anthem plan. That was inaccurate. Campbell's plan is not affiliated with Anthem. Anthem Blue Cross and Blue Shield operates in 14 states, but Texas is not one of them.

Side Effects Public Media is a health reporting collaboration based at WFYI in Indianapolis. We partner with NPR stations across the Midwest and surrounding areas — including KBIA and KCUR in Missouri, Iowa Public Radio, Ideastream in Ohio and WFPL in Kentucky.