Reesha Ahmed of Venus, Texas, was billed almost $2,400 for normal 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 medicine, and discussing her being pregnant care plan, she stated, 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 Value suburb. Ahmed, simply eight weeks pregnant, stated the physician advised her the whole lot in regards to the go to was routine. “Nothing actually stood out,” Ahmed stated. “And, after all, there’s simply loads of pleasure, and so I actually did not suppose twice about something.”
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Her blood exams checked for a number of sexually transmitted infections, her blood kind, and numerous 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 stated.
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 several other blood exams in tandem with Ahmed’s preliminary prenatal go to, together with full blood depend, blood kind, and testing for STIs similar to hepatitis B, syphilis, and HIV.
Service supplier: Ahmed received 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.
Complete invoice: The hospital charged $9,520.02 for the blood exams 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 offers: Ahmed’s state of affairs reveals how hospital-based labs typically cost excessive costs for exams. Even when suppliers are in community, a affected person could be on the hook for hundreds of {dollars} for widespread blood exams which are far cheaper in different settings. Research exhibits hospitals typically charge much more than doctor’s workplaces or unbiased industrial labs for a similar exams.
The state of affairs was significantly 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 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 do not really feel such as you had been accurately despatched? It is simply, it is quite a bit,” she stated.
In Texas, the identical lab exams had been no less than six times as expensive in a hospital as in a health care provider’s workplace, in response to analysis from the Well being Care Value Institute, a nonprofit that examines well being spending.
The markup could be even larger relying on the check. HCCI knowledge, primarily based on 2019 costs, exhibits the median worth for a whole 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 performed proper in the identical constructing,” stated Jessica Chang, a senior researcher at HCCI, however “many sufferers aren’t fascinated by how extremely marked up these lab exams are.” Chang stated she suspects many hospitals tack on their overhead prices after they invoice insurance coverage.
Anthem additionally charged Ahmed for no less than 4 exams that almost all insurance policy would contemplate preventive care and due to this fact lined without charge to sufferers beneath the Reasonably priced Care Act’s necessities for overlaying 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 pink blood cells — in addition to for exams for hepatitis B, hepatitis C, and syphilis.
Requested to evaluation 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, stated 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 patients for a number of infectious illnesses that pose main dangers throughout being pregnant. Ina Park, a professor of household group drugs on the College of California-San Francisco and an skilled on STIs, stated the exams Ahmed acquired did not elevate pink flags from a scientific perspective. “It is actually extra what the precise lab charged primarily based on what the exams truly value,” Park stated. “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 screen for syphilis; her out-of-pocket value was $50.74.
“You simply surprise, 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 stated.
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 stated she was bounced between the physician’s workplace and the hospital billing division. Ahmed submitted a criticism to the Texas legal professional common’s workplace, which handed it to the Texas Well being and Human Providers Fee. She by no means heard again.
In accordance with Ahmed, a hospital consultant advised her bloodwork may need been coded incorrectly and agreed the costs “had been actually unusually excessive,” however she was advised there was nothing the hospital might do to alter it. The hospital didn’t touch upon the explanation 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 attraction with Anthem, however it was denied. The insurance coverage firm said the claims had been processed accurately 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 info concerning what medical care was wanted and delivered,” Snooks stated. 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 known as Ahmed on Oct. 10 and stated it might zero out her payments and take away the costs 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 stated.
Texas Well being Assets and AdventHealth declined to answer detailed questions on Ahmed’s prices 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 offer our sufferers with protected, efficient and medically acceptable care,” Laura Shea, a spokesperson for the hospital, stated 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 will warrant larger costs, Chang stated. That holds true for different providers, too, like imaging. “There’s nothing particular in regards to 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 situation. Congress is contemplating laws that will equalize funds for sure providers no matter whether or not they’re supplied 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, 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 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 exams. 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.
In accordance with the Nationwide Convention of State Legislatures, Colorado, Connecticut, Ohio, New York, and Texas have limited providers’ ability to charge privately insured sufferers facility charges for sure providers. 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 can assist sufferers keep away from out-of-pocket prices for really useful 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 performed there. If they can not 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 stated.
KFF Health News, previously generally 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.
