When a Screening Colonoscopy Becomes Diagnostic: Educating Patients on Financial Responsibility

A patient comes into your ASC and undergoes a screening colonoscopy. Polyps are found during the procedure and are removed. Considering the circumstances, this sounds like good news. The screening served its purpose. You detected and removed cancer precursor lesions, hopefully helping to prevent the disease.

There’s just one problem: The patient is angry. Not about the successful removal of the polyps, but about how a change in type of procedure also changed the patient’s financial responsibility. A scheduled screening colonoscopy has become a diagnostic colonoscopy. Rather than being a preventative service provided at no cost to the patient after their insurance has processed the claim, the patient now owes a payment – possibly one considered quite significant.

Guidance for Screening Colonoscopy Education

By taking a proactive approach to colonoscopy education, your ASC can help reduce its number of upset patients. You may even improve their satisfaction in the process. Here are some recommendations on how to help patients understand their potential financial responsibilities before undergoing a colonoscopy.

Develop Documentation

Alleviate some of the confusion about colonoscopies by providing patients with documentation explaining possible outcomes of their screening colonoscopy. Share background on preventative services, noting limitations on this provision. Explain how the definition of a preventative service is adjusted due to changing (and strict) insurance guidelines. Elaborate on how this may affect patients scheduled for a screening colonoscopy and their financial responsibility. Define the categories of colonoscopies: screening/preventative, diagnostic/therapeutic, and surveillance/high-risk.

This background information will hopefully help patients gain a better understanding of colonoscopies. Then summarize what can happen when patients receive a screening colonoscopy referral. Describe how categorization can change based on information captured during the scheduling and pre-procedure processes. Consider addressing some frequently asked questions, such as whether physicians can change a diagnosis so a procedure can qualify as screening and why insurance companies may seem to indicate that your ASC can alter a CPT or diagnosis code.

Share Benefits Information

Along with this documentation, provide patients with information about their colonoscopy benefits. Give your benefits coordinator a form to fill out when they review coverage information online and/or contact patients’ insurance carriers. This form would include details on patients’ covered benefits concerning screening and diagnostic colonoscopies. It would also state patients’ financial responsibilities (or potential responsibilities), broken down by co-pay and deductible.

You may want to include details about payment plans your ASC offers on this form. This can help patients start planning how they will pay for their care if the colonoscopy categorization changes. Include this form with the background documentation.

Speak Directly With Patients

While these documents should better prepare patients for their colonoscopy and possible financial outcomes, calls to patients are also worthwhile. Use this opportunity to review the information in the documentation and form. Ensure individuals at your ASC who speak with patients can explain the difference between screening and diagnostic colonoscopies. Staff should receive training to help them effectively communicate with patients and accurately answer questions.

Quick Tips for Dealing With Upset Patients

Despite your best educational efforts, you may still receive phone calls from upset patients following their colonoscopy. Consider following these steps to help address their concerns:

  • Let them vent. If patients sound animated, give them time to share their thoughts and feelings. Avoid interrupting and try to respond only when asked a question. Giving patients this opportunity to vent can help them calm down and become more focused on the discussion to follow.
  • Remain polite. Throughout your conversation, strive to remain polite, listen carefully and remain calm. If patients believe you are becoming frustrated, not listening closely, or failing to take their concerns seriously, they are likely to become angry.
  • Review case history. Help patients feel like you take their concerns seriously by discussing the details of their situation. Pull up their chart and bill. Talk through the procedure: what was scheduled and found, and how that affected information submitted to their insurance carrier. Verify that your ASC properly coded and billed the procedure.
  • Explain insurance rules. After discussing the case history, patients may still question what they owe. Describe health insurance rules and how they dictate changes in colonoscopy categorization. Provide education on diagnosis codes and your ASC’s requirements to code based on the procedures performed, not scheduled. Discuss the claims submission process and how that triggers the health insurance reimbursement process. Note: If patients spoke with their insurance before you, they may have been told that had you coded the procedure as a screening colonoscopy, it would have been covered. Be prepared to explain the potential fraud implications of improper coding and billing.

Going through these steps can provide comfort to patients and help them better appreciate your ASC’s responsibilities. Once you address any outstanding questions, move to the discussion about how patients will cover what they owe. Be cognizant that patients may be in a delicate state as they come to accept their financial responsibility. Help relieve some stress by informing them of payment options that can spread their financial responsibility over time. While patients may express displeasure with what they’re hearing, patience and compassion can move the situation toward a positive resolution.


Catherine Sayers, Director of Operations