Reesha Ahmed of Venus, Texas, was billed almost $2,400 for traditional blood exams following her first prenatal checkup.
Nitashia Johnson/KFF Well being Information
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Nitashia Johnson/KFF Well being Information
Reesha Ahmed was on cloud 9.
It was January and Ahmed was at an OB-GYN’s workplace close to her residence 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 advised her all the things concerning the go to was routine. “Nothing actually stood out,” Ahmed mentioned. “And, after all, there’s simply a number of pleasure, and so I actually did not suppose twice about something.”
Invoice of the Month is a crowdsourced investigation by KFF Well being Information and NPR that dissects and explains medical payments. Do you will have an attention-grabbing medical invoice you wish to share with us? Inform us about it!
Her blood exams checked for a number of sexually transmitted infections, her blood sort, and numerous hormones. Inside days, Ahmed started bleeding and her pleasure turned to concern. A repeat ultrasound in early February confirmed no fetus.
“My coronary heart type 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 means 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 sort, and testing for STIs similar to 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 Sources, a faith-based nonprofit well being system, and AdventHealth, one other non secular nonprofit.
Complete invoice: The hospital charged $9,520.02 for the blood exams and pathology providers. The insurer negotiated that all the way down to $6,700.50 after which paid $4,310.38, leaving Ahmed with a lab invoice of $2,390.12.
What provides: Ahmed’s scenario reveals how hospital-based labs usually cost excessive costs for exams. Even when suppliers are in community, a affected person might be on the hook for 1000’s of {dollars} for frequent blood exams which might be far cheaper in different settings. Analysis exhibits hospitals usually cost way more than doctor’s places of work or unbiased industrial labs for a similar exams.
The scenario was notably troublesome for Ahmed as a result of she had misplaced the being pregnant.
“To come back to phrases with it mentally, emotionally, bodily — coping with the ramifications of the miscarriage — after which having to muster up the combating energy to then begin calling your insurance coverage, and the billing division, the supplier’s workplace, making an attempt to combat again a invoice that you do not really feel such as you had been appropriately despatched? It is simply, it is loads,” she mentioned.
In Texas, the identical lab exams had been a minimum of six instances as costly in a hospital as in a physician’s workplace, in response to analysis from the Well being Care Value Institute, a nonprofit that examines well being spending.
The markup might be even increased 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 completed proper in the identical constructing,” mentioned Jessica Chang, a senior researcher at HCCI, however “many sufferers should not serious about how extremely marked up these lab exams are.” Chang mentioned she suspects many hospitals tack on their overhead prices after they invoice insurance coverage.
Anthem additionally charged Ahmed for a minimum of 4 exams that the majority insurance policy would take into account preventive care and due to this fact coated without charge to sufferers beneath the Inexpensive Care Act’s necessities for protecting preventive care, which incorporates features 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 e mail to KFF Well being Information that the claims “had been submitted as diagnostic — not preventive — and had been paid in response to the advantages within the member’s well being plan.”
There “positively should not be” out-of-pocket prices for these screenings, mentioned Sabrina Corlette, co-director of Georgetown College’s Middle on Well being Insurance coverage Reforms.
The Facilities for Illness Management and Prevention recommends screening pregnant sufferers for a number of infectious ailments that pose main dangers throughout being pregnant. Ina Park, a professor of household group drugs on the College of California-San Francisco and an professional on STIs, mentioned the exams Ahmed acquired did not increase crimson flags from a medical perspective. “It is actually extra what the precise lab charged based mostly on what the exams really value,” Park mentioned. “This can be 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 concerning the prices, she mentioned she was bounced between the physician’s workplace and the hospital billing division. Ahmed submitted a criticism to the Texas lawyer normal’s workplace, which handed it to the Texas Well being and Human Providers Fee. She by no means heard again.
Based on Ahmed, a hospital consultant advised her bloodwork may need been coded incorrectly and agreed the fees “had been actually unusually excessive,” however she was advised there was nothing the hospital may do to vary it. The hospital didn’t touch upon the rationale behind the excessive cost. And in a March 7 e mail, an AdventHealth worker advised Ahmed the physician’s workplace had “no management” over the hospital’s billing.
Ahmed filed an enchantment with Anthem, however it was denied. The insurance coverage firm acknowledged the claims had been processed appropriately beneath her advantages, which cowl 80% of what the insurer agrees to pay for in-network lab providers 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 data concerning 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 might zero out her payments and take away the fees from collections. Ahmed was relieved, “like a large burden’s simply been lifted off my shoulders.”
“It is simply been combating this for 10 months now, and it is lastly gone,” she mentioned.
Texas Well being Sources and AdventHealth declined to answer 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 prime precedence is to supply our sufferers with secure, efficient and medically applicable care,” Laura Shea, a spokesperson for the hospital, mentioned in an emailed assertion.
The takeaway: Ahmed’s downside demonstrates the pitfalls of utilizing a hospital lab for routine testing.
For normal bloodwork “it is actually onerous to argue that there is a high quality distinction” between unbiased labs and hospitals that might warrant increased costs, Chang mentioned. That holds true for different providers, too, like imaging. “There’s nothing particular concerning the machines that hospitals use for a CT or MRI scan. It is the identical machine.”
Broadly, state and federal lawmakers are being attentive to this difficulty. Congress is contemplating laws that might equalize funds for sure providers no matter whether or not they’re offered in a hospital outpatient division or a physician’s workplace, though not lab providers. Hospitals have tried to fend off such a coverage, generally known as “site-neutral funds.”
For instance, the Decrease Prices, Extra Transparency Act would require the identical costs beneath Medicare for physician-administered medication 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 Major Care and Well being Workforce Act, would ban hospitals from charging industrial well being plans some facility charges — which they use to cowl working or administrative bills.
Based on 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 providers. Colorado, Connecticut, Maryland, and New York require well being amenities 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 may also help sufferers keep away from out-of-pocket prices for really helpful 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 industrial lab like Labcorp or Quest Diagnostics that’s in your community and have the exams completed there. If they cannot do it electronically, ask for a paper requisition.
“Do not at all times simply go to the lab that your physician recommends to you,” Corlette mentioned.
KFF Well being Information, previously generally known as Kaiser Well being Information (KHN), is a nationwide newsroom that produces in-depth journalism about well being points and is likely one of the core working applications at KFF — the unbiased supply for well being coverage analysis, polling, and journalism.
Emmarie Huetteman of KFF Well being Information edited the digital story, and Taunya English of KFF Well being Information edited the audio story. NPR’s Will Stone edited the audio and digital story.
