Colonoscopy bill denied; why and what to do next


I am 62 and live in Maine.  I have a retiree medical insurance program from my employment in California. I recently had a colonoscopy which my insurance claims is not a covered benefit as it is a screening. I have been told it does not matter. It is covered under the Affordable Care Act. I am not enrolled in any of the new Obama Care plans, only my private retiree plan. Can I still get the screening covered under the Affordable Care Act and if so how do I do this. Thank you

East Coaster Now

Dear East Coaster Now,

Your plan should not reject the claim based upon the fact that it was a screening test.  Quite the opposite – it should be covered with no co-pay, if it met the screening test guidelines.  It’s possible that it did not meet the “screening test” definition.  If you have some illness that requires you to get a colonoscopy more frequently than the guidelines, for example, then the test is not considered “screening”.  Even if it is not considered a screening test, the plan should still cover it as a diagnostic test; this may mean that you pay for it but it counts toward your deductible.

I would take a careful look at the letter that your plan sent you denying the claim.  That letter will tell you how to get the plan to reconsider its decision.  Under the Affordable Care Act, there has to be a particular process for plans to review claims.  You can also ask the doctor who did the test to help you.  It’s possible that they simply put the wrong code on the claim, and they can re-submit it.

There is no way to get coverage for a test that you have already had.  If you discover that your plan does not cover screening colonoscopy tests (this is possible, but not likely), then you might qualify for the Maine Colorectal Cancer Control Program.  The program is open to people whose health insurance does not cover colorectal cancer screening, who earn less than 250% of Federal Poverty ($29,175 for a household of one person), and who are older than 50. You might find out that you are a match.

Linda Riddell

About Linda Riddell

A published author and health policy analyst with 25 years’ experience, Linda Riddell's goal is to alleviate the widespread ailment of not knowing what your health plan can do for you.