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Reesha Ahmed of Venus, Texas, was billed practically $2,400 for normal blood checks following her first prenatal checkup.
Nitashia Johnson/KFF Health News
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Nitashia Johnson/KFF Health News
Reesha Ahmed was on cloud 9.
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 checks.
The lab was inside Texas Health Hospital Mansfield, which opened in December 2020 in a Dallas-Fort Worth suburb. Ahmed, simply eight weeks pregnant, mentioned the physician instructed her all the pieces in regards to the go to was routine. “Nothing actually stood out,” Ahmed mentioned. “And, after all, there’s simply a whole lot of pleasure, and so I actually did not suppose twice about something.”
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Her blood checks checked for a number of sexually transmitted infections, her blood sort, and numerous hormones. Within days, Ahmed started bleeding and her pleasure turned to concern. 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 Shield coverage by means of her employer.
Medical providers: An evaluation of Pap smear outcomes and several other blood checks in tandem with Ahmed’s preliminary prenatal go to, together with full blood depend, blood sort, and testing for STIs reminiscent of hepatitis B, syphilis, and HIV.
Service supplier: Ahmed received her checks at Texas Health Mansfield, a tax-exempt hospital collectively operated by Texas Health Resources, a faith-based nonprofit well being system, and IntroductionHealth, one other spiritual nonprofit.
Total invoice: The hospital charged $9,520.02 for the blood checks 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 scenario reveals how hospital-based labs typically cost excessive costs for checks. Even when suppliers are in community, a affected person will be on the hook for 1000’s of {dollars} for widespread blood checks which might be far cheaper in different settings. Research reveals hospitals sometimes cost rather more than doctor’s workplaces or unbiased industrial labs for a similar checks.
The scenario was significantly troublesome for Ahmed as a result of she had misplaced the being pregnant.
“To come 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, attempting to combat again a invoice that you do not really feel such as you have been appropriately despatched? It’s simply, it is quite a bit,” she mentioned.
In Texas, the identical lab checks have been at the least six instances as costly in a hospital as in a health care provider’s workplace, in keeping with analysis from the Health Care Cost Institute, a nonprofit that examines well being spending.
The markup will be even increased relying on the take a look at. 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 Health charged Ahmed $206.69 for that take a look at alone.
“It is handy to get your lab performed proper in the identical constructing,” mentioned Jessica Chang, a senior researcher at HCCI, however “many sufferers should not eager about how extremely marked up these lab checks are.” Chang mentioned she suspects many hospitals tack on their overhead prices once they invoice insurance coverage.
Anthem additionally charged Ahmed for at the least 4 checks that almost all insurance policy would contemplate preventive care and due to this fact coated for gratis to sufferers underneath the Affordable Care Act’s necessities for protecting preventive care, which incorporates facets of prenatal care. Her EOBs, or “clarification of advantages” notices, present she paid out-of-pocket for a take a look at figuring out her Rh issue — which detects a protein on the floor of purple blood cells — in addition to for checks for hepatitis B, hepatitis C, and syphilis.
Asked to assessment Ahmed’s checks, Anthem spokesperson Emily Snooks wrote in an electronic mail to KFF Health News that the claims “have been submitted as diagnostic — not preventive — and have been paid in keeping 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 University’s Center on Health Insurance Reforms.
The Centers for Disease Control 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 University of California-San Francisco and an professional on STIs, mentioned the checks Ahmed acquired did not increase purple flags from a medical perspective. “It’s actually extra what the precise lab charged primarily based on what the checks really value,” Park mentioned. “This is a very exorbitant worth.”
For instance, Ahmed paid $71.86 in coinsurance for a hepatitis B take a look at 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 mentioned.
The decision: Ahmed refused to pay the payments and Texas Health 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 criticism to the Texas lawyer common’s workplace, which handed it to the Texas Health and Human Services Commission. She by no means heard again.
According to Ahmed, a hospital consultant recommended her bloodwork may need been coded incorrectly and agreed the costs “have been actually unusually excessive,” however she was instructed there was nothing the hospital might do to vary it. The hospital didn’t touch upon the explanation behind the excessive cost. And in a March 7 electronic mail, an IntroductionHealth worker instructed Ahmed the physician’s workplace had “no management” over the hospital’s billing.
Ahmed filed an attraction with Anthem, but it surely was denied. The insurance coverage firm said the claims have been processed appropriately underneath 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 upon well being care suppliers to submit correct billing info relating to what medical care was wanted and delivered,” Snooks mentioned. Asked about reimbursements to the Texas Health lab, she added, “The declare was reimbursed primarily based on the laboratory’s contract with the well being plan.”
After a KFF Health News reporter contacted Texas Health on Oct. 9, the hospital known as Ahmed on Oct. 10 and mentioned it will 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’s simply been preventing this for 10 months now, and it is lastly gone,” she mentioned.
Texas Health Resources and IntroductionHealth declined to reply to detailed questions on Ahmed’s fees and the checks she was directed to acquire.
“We are 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 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 increased costs, Chang mentioned. 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’s the identical machine.”
Broadly, state and federal lawmakers are listening to this problem. 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 called “site-neutral funds.”
For instance, the Lower Costs, More Transparency Act would require the identical costs underneath Medicare for physician-administered medicine 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 checks. Another invoice, the Bipartisan Primary Care and Health Workforce Act, would ban hospitals from charging industrial well being plans some facility charges — which they use to cowl working or administrative bills.
According to the National Conference 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 services to reveal facility charges to sufferers earlier than offering care; Florida instituted comparable necessities for free-standing emergency departments.
Patients ought to maintain copies of itemized payments and insurance coverage statements. While not the one proof, these paperwork can assist sufferers keep away from out-of-pocket prices for advisable preventive screenings.
For now, sufferers can proactively keep away from such excessive payments: When your physician says you want blood checks, ask that the requisition be despatched to a industrial lab like Labcorp or Quest Diagnostics that’s in your community and have the checks performed there. If they cannot 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.
KFF Health News, previously often called Kaiser Health News (KHN), is a nationwide newsroom that produces in-depth journalism about well being points and is among the core working packages at KFF — the unbiased supply for well being coverage analysis, polling, and journalism.
Emmarie Huetteman of KFF Health News edited the digital story, and Taunya English of KFF Health News edited the audio story. NPR’s Will Stone edited the audio and digital story.
