by Matthew Brady

Routine colon screenings turned into a yearlong nightmare for members Mike and Cathy Anderson. Both received clean bills of health, but their medical bills told another story.

"Mine, the insurance paid for," Mike Anderson says. "Hers, the insurance wouldn't pay for, even though we were both precertified."

Twenty-nine states, including Georgia, require insurance companies to cover 100 percent of the cost of a routine colonoscopy screening. But if the screening finds a polyp, it may not qualify for the 100 percent coverage.

The Andersons learned the same applies if the patient has a previous history. One doctor at highly rated Atlanta Gastroenterology Associates, with multiple locations in the Atlanta area, decided Cathy didn't qualify for a "screening" because she had a polyp removed 38 years ago with no symptoms since. He reported it to the insurance company as a pre-existing condition.

A colonoscopy, recommended every 10 years for most healthy adults over age 50, screens patients for potentially cancerous polyps. Of cancers that affect both men and women, colorectal cancer is the second leading cause of cancer-related deaths in the United States and Georgia.

The Andersons' case highlights one of the factors affecting colonoscopy coverage and costs, which can vary by 300 percent in many cities, according to Healthcare Blue Book. Atlanta Gastroenterology charges a cash price of $1,500, which includes physician and facility services, sedation, biopsies and lab work. That falls within the metro Atlanta Blue Book "fair price" range, which starts at $1,126 without a biopsy and $1,510 with a biopsy. The fair price represents what a health service provider typically accepts from insurance companies as full payment, which is substantially less than the billed amount.

Highly rated Metro Atlanta Gastroenterology is slightly higher on the fair-rate scale, charging a cash price of $1,552 without a biopsy; $1,633 with a biopsy. That includes physician and facility fees and sedation, but not lab work, says business manager Kathy Brown.

Jana Baker, practice administrator for Atlanta Gastroenterology, says insurers negotiate their rates based on Medicare reimbursement rates. "The charge amount doesn't matter. What matters is the contract you have with that insurance company," she says. "If we charge $10,000 and the allowed amount is $200, we write off $9,800 as a contractual adjustment."

The Andersons' insurance company, Aetna, finally issued a refund in Cathy's screening vs. diagnostic dispute after nearly a year. "I just had to keep pushing and getting ugly," Mike says. "I think everybody was somewhat at fault, but I really blame the doctor." He gave Dr. Michael S. LeVine a grade of D, his only report on the List.

Baker declined to discuss the Andersons' case or their Angie's List report on LeVine. Clinics must code procedures based on guidelines issued by the Centers for Medicare and Medicaid Services and the National Center for Health Statistics, she says, adding, "That is a battle that is plaguing GI clinics across the country because of the way the insurance companies process this."