Egregious Physician Charges for Screening Colonoscopy Services
ClaimDOC’s comprehensive line-by-line auditing of claims uncovers errors that basic claim repricing and auto-adjudication does not catch, leading to greater savings for health plans and its plan members. Our audit team analyzes all types of healthcare claims for a variety of potential concerns including excessive usual and customary charges, duplication of claims, incorrect coding/billing, unbundling of services and many others. Our claims review is not intended to impact care decisions or medical practice.
In this Claims Audit Spotlight, we focus on a claim example where the physician reported and billed a routine screening colonoscopy procedure with place of service code 11, defined as office.
We asked three (3) questions:
1) Is the physician really charging this much for a routine screening colonoscopy service?
2) Is this an error on the physician claim?
3) Is the physician charge egregious for the type of service provided and billed?
Colonoscopy is a procedure that allows a practitioner to examine the entire colon and when applicable, remove polyps. Colonoscopy was first conceptualized in the 1960s, although the procedure was not widely accepted and practiced until the 1970s. Since then, colonoscopy has been become a standard test for the screening and detection of colorectal cancer and has improved in quality and safety.
According to the Centers for Disease Control and Prevention (CDC), colorectal cancer is the second leading cancer killer of men and women in the United States, following lung cancer. The best screening test is one that is completed. Individuals that elect to undergo colonoscopy, one of several screening options, can reduce their risks of developing and dying from colorectal cancer.
A colonoscopy may be performed in a physician’s office, ambulatory surgical center (ASC), or hospital outpatient setting It is estimated over 15 million colonoscopies are performed across the United States each year.
A 50-year-old male was seen in a physician office located in Illinois for a screening colonoscopy procedure.
The physician claim (CMS-1500/electronic equivalent) was reported/ billed as follows:
CPT code G0121- PT -Charge $42,430.00.
Additional charges were billed in the amount of $2,983.61 for moderate sedation and medications.
Total billed charges for colonoscopy procedure – $45,413.61
According to FAIRHealth® data, depending on the locality where services are performed/zip code, a physician charge for CPT code G0121 can range from $700.00 – $2,140.00 for this service.
ClaimDOC’s reference-based pricing – $484.45 based on the 2023 Medicare Physician Fee Schedule (for non-facility place of service Illinois) with markup.
Plan Savings: $44,947.16
Percentage of Savings: 99%
The concern of egregious charges was observed on the above physician claim. While physicians can charge any amount they elect for provided services, egregious fees and billing/coding errors complicate matters for members to understand their bills and payments, impact the collection of patient balances, build a reputation of physicians charging high fees, create burdens for patients having no insurance and a host of others.
Obtaining pricing estimates prior to needing or having related care to understand how much one is obligated to pay for their services and learning if there are any coverage limitations can be beneficial to avoid surprise medical bills. Whenever an individual receives a bill and the cost for care seems inappropriate/questionable, an inquiry to the provider and/or health plan should be made to obtain an explanation of the service(s) and corresponding charge(s).
Our goal at ClaimDOC is to use benchmark charges and costs nationally to negotiate fair and ethical payments. Employers turn to us to seek and establish fair reimbursement rates for their plans allowing them to save money and provide richer benefits to their employees. A win-win for everyone.