Out for Blood? For Routine Lab Work, the Hospital Billed Her $2,400

By Rachana Pradhan
KFF Information
 

It was January and Ahmed was at an OB-GYN’s workplace close to her house in Venus, Texas, for her first prenatal checkup. After an ultrasound, getting anti-nausea remedy, and discussing her being pregnant care plan, she mentioned, a nurse made a handy suggestion: Head to the lab simply down the corridor for the standard panel of exams.

The lab was inside Texas Well being Hospital Mansfield, which opened in December 2020 in a Dallas-Fort Price suburb. Ahmed, simply eight weeks pregnant, mentioned the physician instructed her the whole lot in regards to the go to was routine. “Nothing actually stood out,” Ahmed mentioned. “And, in fact, there’s simply a variety of pleasure, and so I actually didn’t assume twice about something.”

Her blood exams checked for a number of sexually transmitted infections, her blood kind, and varied hormones. Inside days, Ahmed started bleeding and her pleasure turned to worry. A repeat ultrasound in early February confirmed no fetus.

“My coronary heart form of fell aside at that second as a result of I knew precisely what that meant,” she mentioned. She would have a miscarriage.

Then the payments got here.

The Affected person: Reesha Ahmed, 32, has an Anthem Blue Cross and Blue Protect coverage by way of her employer.

Medical Providers: An evaluation of Pap smear outcomes and a number of other blood exams in tandem with Ahmed’s preliminary prenatal go to, together with full blood rely, blood kind, and testing for STIs reminiscent of hepatitis B, syphilis, and HIV.

Service Supplier: Ahmed acquired her exams at Texas Well being Mansfield, a tax-exempt hospital collectively operated by Texas Well being Assets, a faith-based nonprofit well being system, and AdventHealth, one other spiritual nonprofit.

Whole Invoice: The hospital charged $9,520.02 for the blood exams and pathology companies. The insurer negotiated that right down to $6,700.50 after which paid $4,310.38, leaving Ahmed with a lab invoice of $2,390.12.

What Offers: Ahmed’s scenario reveals how hospital-based labs typically cost excessive costs for exams. Even when suppliers are in community, a affected person may be on the hook for 1000’s of {dollars} for frequent blood exams which might be far cheaper in different settings. Analysis exhibits hospitals sometimes cost way more than physicians’ places of work or unbiased business labs for a similar exams.

The scenario was notably tough for Ahmed as a result of she had misplaced the being pregnant.

“To return to phrases with it mentally, emotionally, bodily — coping with the ramifications of the miscarriage — after which having to muster up the preventing power to then begin calling your insurance coverage, and the billing division, the supplier’s workplace, making an attempt to battle again a invoice that you simply don’t really feel such as you had been accurately despatched? It’s simply, it’s quite a bit,” she mentioned.

In Texas, the identical lab exams had been not less than six instances as costly in a hospital as in a physician’s workplace, based on analysis from the Well being Care Price Institute, a nonprofit that examines well being spending.

The markup may be even larger relying on the check. HCCI knowledge, based mostly on 2019 costs, exhibits the median value for a whole blood rely in Texas was $6.34 at an unbiased lab and $58.22 at a hospital. Texas Well being charged Ahmed $206.69 for that check alone.

“It’s handy to get your lab carried out proper in the identical constructing,” mentioned Jessica Chang, a senior researcher at HCCI, however “many sufferers aren’t interested by how extremely marked up these lab exams are.” Chang mentioned she suspects many hospitals tack on their overhead prices once they invoice insurance coverage.

Anthem additionally charged Ahmed for not less than 4 exams that almost all insurance policy would think about preventive care and due to this fact lined for free of charge to sufferers beneath the Inexpensive Care Act’s necessities for masking preventive care, which incorporates points of prenatal care. Her EOBs, or “clarification of advantages” notices, present she paid out-of-pocket for a check figuring out her Rh issue — which detects a protein on the floor of crimson blood cells — in addition to for exams for hepatitis B, hepatitis C, and syphilis.

Requested to assessment Ahmed’s exams, Anthem spokesperson Emily Snooks wrote in an electronic mail to KFF Well being Information that the claims “had been submitted as diagnostic — not preventive — and had been paid based on the advantages within the member’s well being plan.”

There “positively shouldn’t be” out-of-pocket prices for these screenings, mentioned Sabrina Corlette, co-director of Georgetown College’s Heart on Well being Insurance coverage Reforms.

The Facilities for Illness Management and Prevention recommends screening pregnant sufferers for a number of infectious illnesses that pose main dangers throughout being pregnant. Ina Park, a professor of household group medication on the College of California-San Francisco and an professional on STIs, mentioned the exams Ahmed acquired didn’t elevate crimson flags from a medical perspective. “It’s actually extra what the precise lab charged based mostly on what the exams really value,” Park mentioned. “It is a actually exorbitant value.”

For instance, Ahmed paid $71.86 in coinsurance for a hepatitis B check for which the hospital charged $418.55. The hospital charged $295.52 to display for syphilis; her out-of-pocket value was $50.74.

“You simply marvel, is the insurance coverage firm actually negotiating with this supplier as aggressively as they need to to maintain the reimbursement to an affordable quantity?” Corlette mentioned.

The Decision: Ahmed refused to pay the payments and Texas Well being despatched the debt to collections. When she tried to get solutions in regards to the prices, she mentioned she was bounced between the physician’s workplace and the hospital billing division. Ahmed submitted a grievance to the Texas legal professional basic’s workplace, which handed it to the Texas Well being and Human Providers Fee. She by no means heard again.

In response to Ahmed, a hospital consultant prompt her bloodwork may need been coded incorrectly and agreed the fees “had been actually unusually excessive,” Ahmed mentioned, however she was instructed there was nothing the hospital may do to alter it. The hospital didn’t touch upon the rationale behind the excessive cost. And in a March 7 electronic mail, an AdventHealth worker instructed Ahmed the physician’s workplace had “no management” over the hospital’s billing.

Ahmed filed an enchantment with Anthem, nevertheless it was denied. The insurance coverage firm acknowledged the claims had been processed accurately beneath her advantages, which cowl 80% of what the insurer agrees to pay for in-network lab companies after she meets her deductible. Ahmed has a $1,400 deductible and a $4,600 out-of-pocket most for in-network suppliers.

“We rely on well being care suppliers to submit correct billing info relating to what medical care was wanted and delivered,” Snooks mentioned. Requested about reimbursements to the Texas Well being lab, she added, “The declare was reimbursed based mostly on the laboratory’s contract with the well being plan.”

After a KFF Well being Information reporter contacted Texas Well being on Oct. 9, the hospital known as Ahmed on Oct. 10 and mentioned it will zero out her payments and take away the fees from collections. Ahmed was relieved, “like an enormous burden’s simply been lifted off my shoulders.”

“It’s simply been preventing this for 10 months now, and it’s lastly gone,” she mentioned.

Texas Well being Assets and AdventHealth declined to reply to detailed questions on Ahmed’s expenses and the exams she was directed to acquire.

“We’re sorry Ms. Ahmed didn’t get readability on her care with us. Our high precedence is to supply our sufferers with secure, efficient and medically acceptable care,” Laura Shea, a spokesperson for the hospital, mentioned in an emailed assertion.

The Takeaway: Ahmed’s drawback demonstrates the pitfalls of utilizing a hospital lab for routine testing.

For traditional bloodwork “it’s actually laborious to argue that there’s a high quality distinction” between unbiased labs and hospitals that might warrant larger costs, Chang mentioned. That holds true for different companies, too, like imaging. “There’s nothing particular in regards to the machines that hospitals use for a CT or MRI scan. It’s the identical machine.”

Broadly, state and federal lawmakers are taking note of this difficulty. Congress is contemplating laws that might equalize funds for sure companies no matter whether or not they’re offered in a hospital outpatient division or a physician’s workplace, though not lab companies. Hospitals have tried to fend off such a coverage, often called “site-neutral funds.”

For instance, the Decrease Prices, Extra Transparency Act would require the identical costs beneath Medicare for physician-administered medicine no matter whether or not they’re given in a physician’s workplace or an off-campus hospital outpatient division. That invoice additionally would require labs to make public the costs they cost Medicare for exams. One other invoice, the Bipartisan Main Care and Well being Workforce Act, would ban hospitals from charging business well being plans some facility charges — which they use to cowl working or administrative bills.

In response to the Nationwide Convention of State Legislatures, Colorado, Connecticut, Ohio, New York, and Texas have restricted suppliers’ means to cost privately insured sufferers facility charges for sure companies. Colorado, Connecticut, Maryland, and New York require well being services to reveal facility charges to sufferers earlier than offering care; Florida instituted related necessities for free-standing emergency departments.

Sufferers ought to hold copies of itemized payments and insurance coverage statements. Whereas not the one proof, these paperwork will help sufferers keep away from out-of-pocket prices for beneficial preventive screenings.

For now, sufferers can proactively keep away from such excessive payments: When your physician says you want blood exams, ask that the requisition be despatched to a business lab like Labcorp or Quest Diagnostics that’s in your community and have the exams carried out there. If they will’t do it electronically, ask for a paper requisition.

“Don’t all the time simply go to the lab that your physician recommends to you,” Corlette mentioned.

Stephanie O’Neill reported the audio story.

Invoice of the Month is a crowdsourced investigation by KFF Well being Information and NPR that dissects and explains medical payments. Do you’ve gotten an attention-grabbing medical invoice you need to share with us? Inform us about it!

KFF Well being Information is a nationwide newsroom that produces in-depth journalism about well being points and is without doubt one of the core working applications at KFF—an unbiased supply of well being coverage analysis, polling, and journalism. Be taught extra about KFF.

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