Reesha Ahmed of Venus, Texas, was billed practically $2,400 for normal blood assessments 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 dwelling in Venus, Texas, for her first prenatal checkup. After an ultrasound, getting anti-nausea treatment, 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 assessments.
The lab was inside Texas Well being Hospital Mansfield, which opened in December 2020 in a Dallas-Fort Value suburb. Ahmed, simply eight weeks pregnant, mentioned the physician instructed her all the things concerning the go to was routine. “Nothing actually stood out,” Ahmed mentioned. “And, in fact, there’s simply numerous pleasure, and so I actually did not assume 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 assessments checked for a number of sexually transmitted infections, her blood sort, 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 sort 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 her employer.
Medical providers: An evaluation of Pap smear outcomes and several other blood assessments in tandem with Ahmed’s preliminary prenatal go to, together with full blood depend, blood sort, and testing for STIs resembling hepatitis B, syphilis, and HIV.
Service supplier: Ahmed acquired her assessments 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 assessments and pathology providers. 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 provides: Ahmed’s state of affairs reveals how hospital-based labs typically cost excessive costs for assessments. Even when suppliers are in community, a affected person could be on the hook for 1000’s of {dollars} for widespread blood assessments which are far cheaper in different settings. Analysis reveals hospitals sometimes cost way more than doctor’s workplaces or unbiased industrial labs for a similar assessments.
The state of affairs was significantly 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 energy to then begin calling your insurance coverage, and the billing division, the supplier’s workplace, making an attempt to struggle again a invoice that you do not really feel such as you have been appropriately despatched? It is simply, it is lots,” she mentioned.
In Texas, the identical lab assessments have been at the very least six instances as costly in a hospital as in a health care provider’s workplace, in accordance with analysis from the Well being Care Value Institute, a nonprofit that examines well being spending.
The markup could be even greater relying on the check. HCCI knowledge, primarily based on 2019 costs, reveals the median worth for an entire blood depend 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 will not be eager about how extremely marked up these lab assessments are.” Chang mentioned she suspects many hospitals tack on their overhead prices after they invoice insurance coverage.
Anthem additionally charged Ahmed for at the very least 4 assessments that the majority insurance coverage would think about preventive care and subsequently coated for free of charge to sufferers beneath the Reasonably priced Care Act’s necessities for masking preventive care, which incorporates points of prenatal care. Her EOBs, or “rationalization 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 assessments for hepatitis B, hepatitis C, and syphilis.
Requested to evaluate Ahmed’s assessments, Anthem spokesperson Emily Snooks wrote in an electronic mail to KFF Well being Information that the claims “have been submitted as diagnostic — not preventive — and have been paid in accordance with 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 neighborhood drugs on the College of California-San Francisco and an skilled on STIs, mentioned the assessments Ahmed obtained did not increase crimson flags from a scientific perspective. “It is actually extra what the precise lab charged primarily based on what the assessments truly value,” Park mentioned. “This can be a actually exorbitant worth.”
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 inexpensive 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 Companies Fee. She by no means heard again.
Based on Ahmed, a hospital consultant instructed her bloodwork might need been coded incorrectly and agreed the costs “have been actually unusually excessive,” however she was instructed there was nothing the hospital may do to vary it. The hospital didn’t touch upon the explanation 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 attraction with Anthem, however it was denied. The insurance coverage firm acknowledged the claims have 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 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 primarily based 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 referred to as Ahmed on Oct. 10 and mentioned it will zero out her payments and take away the costs from collections. Ahmed was relieved, “like an enormous burden’s simply been lifted off my shoulders.”
“It is simply been preventing this for 10 months now, and it is lastly gone,” she mentioned.
Texas Well being Assets and AdventHealth declined to answer detailed questions on Ahmed’s fees and the assessments she was directed to acquire.
“We’re sorry Ms. Ahmed didn’t get readability on her care with us. Our prime precedence is to offer 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 arduous to argue that there is a high quality distinction” between unbiased labs and hospitals that will warrant greater 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 concern. Congress is contemplating laws that will equalize funds for sure providers no matter whether or not they’re offered in a hospital outpatient division or a health care provider’s workplace, though not lab providers. Hospitals have tried to fend off such a coverage, often 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 health care provider’s workplace or an off-campus hospital outpatient division. That invoice additionally would require labs to make public the costs they cost Medicare for assessments. One other invoice, the Bipartisan Main 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’ potential 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 can assist 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 assessments, ask that the requisition be despatched to a industrial lab like Labcorp or Quest Diagnostics that’s in your community and have the assessments carried out 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 often known as Kaiser Well being Information (KHN), is a nationwide newsroom that produces in-depth journalism about well being points and is among 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.
