A Guide to Health Cover for Colonoscopies
Colonoscopies are an important tool for diagnosing bowel cancer, inflammatory bowel disease, and other conditions that affect the large intestine or rectum. Regular colonoscopies are particularly important for people aged over 50, or for those with an elevated risk of bowel cancer.
So you may be wondering, are colonoscopies covered by health insurance and does Medicare cover colonoscopies? These are important questions, and we have the answers for you.
Key Points
Medicare typically covers 75% of the scheduled fee for colonoscopies. Colonoscopy health insurance often covers the remaining 25%.
83% of patients with colonoscopy level cover had no out-of-pocket costs.
Of the 17% of patients who had an out-of-pocket cost, people typically paid $150.
For people without colonoscopy health insurance, Medicare typically covers the full cost of colonoscopies when treated as a public patient in a public hospital.
Bowel Cancer Australia recommends that people who may be experiencing symptoms of bowel cancer should have a colonoscopy within 30 days.
However, public hospital waiting times for a colonoscopy can be as high as 181 days.
What is a colonoscopy?
A colonoscopy is a diagnostic procedure doctors use to examine the inner lining of the rectum and large intestine. During the procedure, the patient is typically anaesthetised, and a flexible tube with a light and a small camera at the end – known as an endoscope – is inserted into the patient’s rectum and guided through the entire length of their colon.
While a colonoscopy is a type of endoscopy, different endoscopes can also be used to examine other parts of the body including the oesophagus, lungs, stomach, the beginning of the small intestine, and the urinary and reproductive systems.
COMPARE & SAVEWhat do colonoscopies treat?
Colonoscopies are commonly used to detect polyps, inflammation, ulcers, and cancers that may be present in the rectum or large intestine. Polyps can often be removed during a colonoscopy, and tissue samples may be taken for further testing – known as a biopsy.
Regular colonoscopies are typically recommended for people over the age of 50, or for anyone who may be at a higher risk of developing bowel cancer. They may also be used to diagnose and monitor the progression of inflammatory bowel disease.
Other types of endoscopies are often used to diagnose and assess the severity of a range of respiratory, stomach, digestive, urinary, and reproductive conditions and disorders.
Is colonoscopy covered by health insurance?
Many private health insurance policies do cover colonoscopies. However, your out-of-pocket expenses will typically depend on the amount your specialist charges, and the specific details of your insurance policy.
For people with health insurance that covers colonoscopies, Medicare commonly covers 75% of the scheduled fee as listed on the Medicare Benefits Schedule (MBS). Your health fund will often cover the remaining 25%.
However, some specialists may charge more than the scheduled fee. The difference between the scheduled fee and the fee your specialist charges is known as the gap.
Some health funds have no-gap agreements or gap cover schemes that will take care of all or some of the gap payment for you. Otherwise, you’ll need to pay the gap payment yourself. This is known as an out-of-pocket expense.
If you have appropriate health insurance and are admitted to a private hospital, your health fund may also cover the cost of your hospital stay.
All of the above is typically true for other types of endoscopies as well.
How much does a colonoscopy cost?
So, how much does an endoscopy and colonoscopy cost, and how many people with private health insurance have to cover out-of-pocket costs?
According to Australian Government Department of Health and Aged Care for the period 2021-22:
83% of patients had no out-of-pocket costs
17% of patients had out-of-pocket costs
Of the 17% of patients who had an out-of-pocket cost, people typically paid $150
Here’s how that breaks down:
Specialists’ fee | Medicare paid | Health insurer paid | Patients’ paid |
|---|---|---|---|
$1,200 | $560 | $470 | $150 |
*Based on typical colonoscopy costs in 2021-22 for patients with private health insurance.
Are colonoscopies covered by Medicare Australia?
Medicare typically covers colonoscopies, which means there is usually no cost for a colonoscopy if you are admitted to a public hospital as a public patient.
However, for Medicare to cover the cost of a colonoscopy-related procedure, it must be listed on the MBS in one of the following categories:
MBS item number | Procedure description |
|---|---|
32222 | During the colonoscopy, the doctor might remove polyps or take a tissue sample (biopsy) for further testing. |
32223 | Abnormal tissue (adenoma) has been seen, or there is a personal or family history of cancer in the large bowel (colorectal). |
32224 | A previous colonoscopy has shown some abnormal tissue (adenoma) and non cancerous (benign) tumours. Anaesthesia is administered for the procedure. |
32225 | A previous procedure (colonoscopy) has shown abnormal tissue (adenoma) or growths (polyp). |
32226 | The examination is because family history means the patient has a high risk of bowel (colorectal) cancer. Anaesthesia is given. |
32228 | An endoscope is used to look inside the large intestine (colonoscopy) with anaesthesia given. |
How long are waiting times for colonoscopies?
According to Bowel Cancer Australia, 90% of people who received a positive screen from the Bowel Cancer Screening Program (NBCSP) waited between 116 and 181 days for a colonoscopy.
Here’s why that can be a big problem. Bowel Cancer Australia says people who may be experiencing symptoms of bowel cancer should have a colonoscopy within 30 days. And if the waiting time for a colonoscopy exceeds 120 days, your cancer prognosis can worsen.
Critically, holding appropriate health insurance means you can skip the public waiting list for colonoscopies, and choose your own doctor and a private hospital.
If you're struggling to understand how to best cover your colonoscopy, the friendly health insurance experts at Compare Club are here to help.
COMPARE & SAVESources
Australian Government Department of Health and Aged Care, Colonoscopy Bowel Cancer Australia, A Colonoscopy Wait-time and Performance Guarantee Mayo Clinic, Colonoscopy Mayo Clinic, Endoscopy
MBS item numbers:
32222, 32223, 32224, 32225, 32226, 32228
Disclaimer
This guide is opinion only and should not be taken as financial advice. Check with a financial professional before making any decisions. Compare Club compares selected products from a panel of trusted insurers. We do not compare all products in the market.
