How BCBS Illegally Denied $651 for a Screening Colonoscopy (and How to Fight Back)

Last month, a patient received a $651bill for a screening colonoscopy (HCPCSG0105), a 0-cost service under the ACA. Why? Blue Cross Blue Shield of Illinois auto-reprocessed the claim as “diagnostic” (CPT 00812) to shift costs to the patient.

This isn’t a glitch—it’s a systemic tactic. A 2023 NIH study found that 1 in 4 preventive care claims are wrongly reprocessed by payers, costing clinics and patients $2.3B annually.

Why This Matters to You

• Patient Trust: 68% of patients blame providers—not insurers—for surprise bills.
• Revenue Loss: Denied preventive care claims = lost revenue + costly appeals.
• Legal Risk: Employers/patients are filing DOI complaints (like this case), putting clinics in the crosshairs.

3 Steps to Protect Your Practice

1?? Audit Preventive Care Claims: Use modifiers PT (screening) and 33 (ACA-mandated) to block reprocessing.

2?? Educate Patients: Add a script to your EMR: “If billed for preventive care, contact us—do NOT pay.”

3?? Fight Back: File DOI complaints with patients (we provide templates).

Case Study

Clinic: Tampa Gastro Group

Issue: $18k in wrongful colonoscopy denials (BCBS FL).

Our Fix: Reprocessed claims + DOI complaints → 100% recovery in 21 days.

CTA: “DM us your denial—we’ll audit it for free.”

#MedicalBilling #RCM #HealthcareFraud #DenialManagement #PatientAdvocacy #medbillingRCM