Tom Contos is an avid runner. When he started experiencing rectal bleeding in March, he thought exercise could be the cause and tried to ignore it. But he became increasingly worried when the bleeding continued for weeks.

The Chicago health care consultant contacted his physician at Northwestern Medicine, who referred him for a diagnostic colonoscopy, at least partly because Contos, 45, has a family history of colon issues.

“I work out a lot,” he said. “But my partner said this isn’t normal. My primary care physician said, ‘Given your family history, let’s get you in.’”

Northwestern Memorial Hospital asked him to prepay $1,000 out-of-pocket, and he underwent the procedure in June.

Then the bill came.

The Medical Procedure

Colonoscopies are performed in the United States more than 15 million times a year. Rates of colorectal cancer are on the rise, particularly among younger people.

The procedure, which is also a recommended screening for people 45 or older, involves examining the large intestine using a tube with a video camera that can also collect tissue samples.

It typically takes less than one hour, with another hour spent taking the patient’s history, administering anesthesia, and monitoring their recovery, said Glenn Littenberg, a physician who recently chaired the reimbursement committee of the American Society of Gastrointestinal Endoscopy.

According to Contos’ medical record, the gastroenterologist who performed his colonoscopy described it as “not difficult.” He biopsied and removed small growths called polyps from two spots and identified large internal hemorrhoids, which are swollen veins.

The biopsy samples were sent to pathology for testing and found to be precancerous. But the gastroenterologist reported finding no evidence of cancer, and after reviewing the pathology report, he concluded hemorrhoids were the likely cause of the bleeding.

The Final Bill

The hospital charged a total of $19,206 for the procedure, including physician fees. The insurer negotiated the price to $5,816 and paid $1,979, leaving a patient share of $4,047. (It wasn’t clear why the payments added up to slightly more than the negotiated price.) After Contos had paid $1,000 up front, plus $1,381 right after the procedure, the hospital said he still owed $1,666.

The Billing Problem: Colonoscopies That Find Polyps Cost More

Contos was shocked and angry when he received his itemized bill. “I said, ‘I don’t understand this.’ Then I started to research the cost.”

He asked the hospital what it charges for a diagnostic colonoscopy and was told he’d been sent a cost estimate through his online patient portal prior to the procedure.

The estimate, which took his deductible of $3,200 into account, listed a total price of $7,203, with an out-of-pocket bill of $2,381. He asked Northwestern why the charges were nearly three times the estimate and why his out-of-pocket share was nearly twice as high.

One big reason was revealed in an explanation of benefits (EOB) statement from Contos’ insurance company, Aetna: Northwestern had charged for two colonoscopies, at $5,466 each. And there were two fees for the gastroenterologist — $1,535 and $1,291.

The first procedure was listed as “colonoscopy and biopsy,” while the second was listed as “colonoscopy w/lesion removal.” Aetna’s negotiated member rate reduced the first $5,466 hospital charge to $3,425, while the charge for the second procedure was lowered to $1,787 — $1,638 less.

Neither the bill nor the EOB explained why there was a second procedure listed, at a reduced price.

After examining Contos’ bill, Littenberg said it’s standard for providers to bill for two colonoscopies if they remove two or more polyps in different ways, because of the extra work. As in this case, hospitals typically use a modifier code that reduces the amount charged for the second billed colonoscopy so they charge only for the extra work, he added.

“How do you explain that in sensible terms that anyone could understand?” Littenberg said.

Even with that reduction, Littenberg said, he thought Contos’ total out-of-pocket cost of $4,047 was “a lot, though not rare for large academic centers.”

Contos’ insurance documents show Aetna’s negotiated rate for his colonoscopy at Northwestern was more than twice the insurer’s median negotiated rate for the same procedure at other Chicago-area hospitals, according to Forrest Xiao, director of quantitative research at Turquoise Health, a company that gathers health care price data.

In exchanges with Northwestern and Aetna representatives, Contos asked why he was charged for two colonoscopies. A Northwestern representative said that because of the modifier code, he wasn’t actually being billed for two procedures, which Contos found bewildering.

“I told Northwestern, ‘I’m not paying that, and I don’t care if you send me to collections,’” he said. He filed appeals with the hospital and Aetna but was ultimately told the billing was correct.

The Resolution

In an email, Contos told the billing department that its charge was “ridiculously high.” A representative responded that Northwestern’s pricing is in line with other academic medical centers in Chicago and “non-negotiable” — and that his account would be turned over to a collections agency.

CVS Health spokesperson Phillip Blando said in a written statement to KFF Health News that the claims for Contos were “paid accurately” by Aetna, declining further comment. (CVS Health owns Aetna.)

Northwestern did not respond to multiple requests for comment.

Contos said he wrote to his physician that he was regretfully dropping him and leaving Northwestern entirely because of the health system’s high pricing.

He said he’s still experiencing periodic symptoms, which he relieves with over-the-counter Preparation H. A one-ounce tube of the ointment costs $10.99 at CVS.

The Takeaway

To get a colonoscopy at a lower price, Littenberg said, patients should consider going to a freestanding endoscopy center or ambulatory surgery center not associated with a hospital. A 2023 study found that ambulatory surgery centers billed insurers an average of about $1,030 for a colonoscopy with biopsy or with removal of a polyp, compared with $1,760 at a hospital.

To get a sense of how much a diagnostic colonoscopy could cost, patients can consult a hospital’s price website and an insurer’s cost-estimator website, both required by federal price transparency rules.

Patients also can look up a good-faith estimate of the cash price, which can be lower than the price for patients using insurance to pay for a procedure. In addition, they can check prices through websites such as Turquoise Health and Fair Health, which draw from federal price transparency data or claims data from insurers.

Still, the actual cost could be higher than the estimate if the colonoscopy finds one or more polyps that need to be removed and biopsied, which occurs in at least 40% of all colonoscopies, Littenberg said. Patients should ask whether the price includes those potentially extra services. After all, the point of a diagnostic colonoscopy is to find and, if necessary, treat lesions that could cause problems — regardless of the number found.

It all should be easier for patients, Xiao said: “You shouldn’t have to be a medical billing expert to know what you’re going to pay.”

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Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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