Tagged Bill Of The Month

COVID Catch-22: They Got A Big ER Bill Because Hospitals Couldn’t Test For Virus

Fresh off a Caribbean cruise in early March, John Campbell developed a cough and fever of 104 degrees. He went to his primary care physician and got a flu test, which came up negative.

Then things got strange. Campbell said the doctor then turned to him and said, “I’ve called the ER next door, and you need to go there. This is a matter of public health. They’re expecting you.”

It was March 3, and no one had an inkling yet of just how bad the COVID-19 pandemic would become in the U.S.

At the JFK Medical Center near his home in Boynton Beach, Florida, staffers met him in protective gear, then ran a battery of tests — including bloodwork, a chest X-ray and an electrocardiogram — before sending him home. But because he had not traveled to China — a leading criterion at the time for coronavirus testing — Campbell was not swabbed for the virus.

A $2,777 bill for the emergency room visit came the next month.

Now Campbell, 52, is among those who say they were wrongly billed for the costs associated with seeking a COVID-19 diagnosis.

While most insurers have promised to cover the costs of testing and related services — and Congress passed legislation in mid-March enshrining that requirement — there’s a catch: The law requires the waiver of patient cost sharing only when a test is ordered or administered.

And therein lies the problem. In the early weeks of the pandemic and through mid-April in many places, testing was often limited to those with specific symptoms or situations, likely excluding thousands of people who had milder cases of the virus or had not traveled overseas.

“They do pay for the test, but I didn’t have the test,” said Campbell, who appealed the bill to his insurer, Florida Blue. More on how that turned out later.

“These loopholes exist,” said Wendell Potter, a former insurance industry executive who is now an industry critic. “We’re just relying on these companies to act in good faith.”

Exacerbating the problem: Many of these patients were directed to go to hospital emergency departments — the most expensive place to get care — which can result in huge bills for patients-deductible insurance.

Insurers say they fully cover costs when patients are tested for the coronavirus, but what happens with enrollees who sought a test — but were not given one — is less clear.

KHN asked nine national and regional insurers for specifics about how they are handling these situations.

Results were mixed. Three — UnitedHealthcare, Kaiser Permanente and Anthem — said they do some level of automatic review of potential COVID-related claims from earlier in the pandemic, while a fourth, Quartz, said it would investigate and waive cost sharing for suspected COVID patients if the member asks for a review. Humana said it is reviewing claims made in early March, but only those showing confirmed or suspected COVID. Florida Blue, similarly, said it is manually reviewing claims, but only those involving COVID tests or diagnoses. The remaining insurers pointed to other efforts, such as routine audits that look for all sorts of errors, along with efforts to train hospitals and doctors in the proper COVID billing codes to use to ensure patients aren’t incorrectly hit with cost sharing. Those were Blue Cross Blue Shield of Michigan, CIGNA and the Health Care Services Corp., which operates Blues plans in Illinois, Montana, New Mexico, Oklahoma and Texas.

All nine said patients should reach out to them or appeal a claim if they suspect an error.

To be sure, it would be a complex effort for insurers to go back over claims from March and April, looking for patients that might qualify for a more generous interpretation of the cost waiver because they were unable to get a coronavirus test. And there’s nothing in the CARES Act passed by Congress — or subsequent guidance from regulatory agencies — about what to do in such situations.

Still, insurers could review claims, for example, by looking for patients who received chest X-rays, and diagnoses of pneumonia or high fever and cough, checking to see if any might qualify as suspected COVID cases, even if they were not given a diagnostic test, said Potter.

One thing was clear from the responses: Much of the burden falls on patients who think they’ve been wrongly billed to call that to the attention of the insurer and the hospital, urgent care center or doctor’s office where they were treated.

John Campbell developed a cough and fever of 104 degrees in early March, was directed to an ER and ultimately received a $2,777 bill for the visit. He is among those who say they were wrongly billed for the costs associated with seeking a COVID-19 diagnosis.(Courtesy of John Campbell)

Some states have broader mandates that could be read to require the waiver of cost sharing even if a COVID test was not ordered or administered, said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

But no matter where you live, she said, patients who get bills they think are incorrect should contest them. “I’ve heard a lot of comments that claims are not coded properly,” said Corlette. “Insurers and providers are on a learning curve. If you get a bill, ask for a review.”

Scarce Tests, Rampant Virus

In some places, including the state of Indiana, the city of Los Angeles and St. Louis County, Missouri, a test is now offered to anyone who seeks one. Until recently, tests were scarce and essentially rationed, even though more comprehensive testing could have helped health officials battle the epidemic.

But even in the early weeks, when Campbell and many others sought a diagnosis, insurers nationwide were promising to cover the cost of testing and related services. That was good PR and good public health: Removing cost barriers to testing means more people will seek care and thus could prevent others from being infected. Currently, the majority of insurers offering job-based or Affordable Care Act insurance say they are fully waiving copays, deductibles and other fees for testing, as long as the claims are coded correctly. (The law does not require short-term plans to waive cost sharing.) Some insurers have even promised to fully cover the cost of treatment for COVID, including hospital care.

But getting stuck with a sizable bill has become commonplace. “I only went in because I was really sick and I thought I had it,” said Rayone Moyer, 63, of La Crosse, Wisconsin, who was extra concerned because she has diabetes. “I had a hard time breathing when I was doing stuff.”

On March 27, she went to Gundersen Lutheran Medical Center, which is in her Quartz insurance network, complaining of body aches and shortness of breath. Those symptoms could be COVID-related, but could also signal other conditions. While there, she was given an array of tests, including bloodwork, a chest X-ray and a CT scan.

She was billed in May: $2,421 by the hospital and more than $350 in doctor bills.

“My insurance applied the whole thing to my deductible,” she said. “Because they refused to test me, I’ve got to pay the bill. No one said, ‘Hey, we’ll give you $3,000 worth of tests instead of the $100 COVID test,’” she said.

Quartz spokesperson Christina Ott said patients with concerns like Moyer’s should call the insurance company’s customer service number and ask for an appeals specialist. The insurer, she wrote in response to KHN’s survey of insurers, will waive cost sharing for some members who sought a diagnosis.

“During the public health emergency, if the member presented with similar symptoms as COVID, but didn’t receive a COVID-19 test and received testing for other illnesses on an outpatient basis, then cost sharing would be waived,” she wrote.

Moyer said she has filed an appeal and was notified by the insurer of a review expected in mid-July. Back in Florida, Campbell filed an appeal of his bill with Florida Blue on April 22, but didn’t hear anything until the day after a KHN reporter called the insurer about his case in June.

Then, Campbell received phone calls from Florida Blue representatives. A supervisor apologized, saying the insurer should not have billed him and that 100% of his costs would be covered.

“Basically they said, ‘We’ve changed our minds,’” said Campbell. “Because I was there so early on, and the bill was coded incorrectly.”

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Essential Worker Shoulders $1,840 Pandemic Debt Due To COVID Cost Loophole

Carmen Quintero works an early shift as a supervisor at a 3M distribution warehouse that ships N95 masks to a nation under siege from the coronavirus. On March 23, she had developed a severe cough, and her voice, usually quick and enthusiastic, was barely a whisper.

A human resources staff member told Quintero she needed to go home.

“They told me I couldn’t come back until I was tested,” said Quintero, who was also told that she would need to document that she didn’t have the virus.

Her primary care doctor directed her to the nearest emergency room for testing because the practice had no coronavirus tests.

The Corona Regional Medical Center is just around the corner from her house in Corona, California, and there a nurse tested her breathing and gave her a chest X-ray. But the hospital didn’t have any tests either, and the nurse told her to go to Riverside County’s public health department. There, a public health worker gave her an 800 number to call to schedule a test. The earliest the county could test her was April 7, more than two weeks later.

At the hospital, Quintero got a doctor’s note saying she should stay home from work for a week, and she was told to behave as if she had COVID-19, isolating herself from vulnerable household members. That was difficult — Quintero lives with her grandmother and her girlfriend’s parents — but she managed. No one else in her home got sick, and by the time April 7 came, she felt better and decided not to get the coronavirus test.

Then the bill came.

The Patient: Carmen Quintero, 35, a supervisor at a 3M distribution warehouse who lives in Corona, California. She has an Anthem Blue Cross health insurance plan through her job with a $3,500 annual deductible.

Total Bill: Corona Regional Medical Center billed Quintero $1,010, and Corona Regional Emergency Medical Associates billed an additional $830 for physician services. She also paid $50 at Walgreens to fill a prescription for an inhaler.

Service Provider: Corona Regional Medical Center, a for-profit hospital owned by Universal Health Services, a company based in King of Prussia, Pennsylvania, which is one of the largest health care management companies in the nation. The hospital contracts with Corona Regional Emergency Medical Associates, part of Emergent Medical Associates.

Medical Service: Quintero was evaluated in the emergency room for symptoms consistent with COVID-19: a wracking cough and difficulty breathing. She had a chest X-ray and a breathing treatment and was prescribed an inhaler.

What Gives: On that day in late March when her body shook from coughing, Quintero’s immediate worry was infecting her family, especially her girlfriend’s parents, both over 65, and her 84-year-old grandmother.

“If something was to happen to them, I don’t know if I would have been able to live with it,” said Quintero.

Quintero wanted to isolate in a hotel, but she could hardly afford to for the week that she stayed home. She had only three paid sick days and was forced to take vacation time until her symptoms subsided and she was allowed back at work. At the time, few places provided publicly funded hotel rooms for sick people to isolate, and Quintero was not offered any help.

For her medical care, Quintero knew she had a high-deductible plan yet felt she had no choice but to follow her doctor’s advice and go to the nearest emergency room to get tested. She assumed she would get the test and not have to pay. Congress had passed the CARES Act just the week before, with its headlines saying coronavirus testing would be free.

That legislation turned out to be riddled with loopholes, especially for people like Quintero who needed and wanted a coronavirus test but couldn’t get one early in the pandemic.

“I just didn’t think it was fair because I went in there to get tested,” she said.

Carmen Quintero (right) still tries to keep a safe distance from her grandmother, Teresa Carapia, and two other family members over 65. Quintero says she worried about them as she tried to self-isolate with COVID-like symptoms.(Heidi de Marco/KHN)

Some insurance companies are voluntarily reducing copayments for COVID-related emergency room visits. Quintero said her insurer, Anthem Blue Cross, would not reduce her bill. Anthem would not discuss the case until Quintero signed its own privacy waiver; it would not accept a signed standard waiver KHN uses. The hospital would not discuss the bill with a reporter unless Quintero could also be on the phone, something that has yet to be arranged around Quintero’s workday, which begins at 4 a.m. and ends at 3:30 p.m.

Three states have gone further than Congress to waive cost sharing for testing and diagnosis of pneumonia and influenza, given these illnesses are often mistaken for COVID-19. California is not one of them, and because Quintero’s employer is self-insured — the company pays for health services directly from its own funds — it is exempt from state directives anyway. The U.S. Department of Labor regulates all self-funded insurance plans. In 2019, nearly 2 in 3 covered workers were in these types of plans.

Resolution: As lockdown restrictions ease and coronavirus cases rise around the country, public health officials say quickly isolating sick people before the virus spreads through families is essential.

But isolation efforts have gotten little attention in the U.S. Nearly all local health departments, including Riverside County, where Quintero lives, now have these programs, according to the National Association of County and City Health Officials. Many were designed to shelter people experiencing homelessness but can be used to isolate others.

Raymond Niaura, interim chairman of the Department of Epidemiology at New York University, said these programs are used inconsistently and have been poorly promoted to the public.

“No one has done this before and a lot of what’s happening is that people are making it up as they go along,” said Niaura. “We’ve just never been in a circumstance like this.”

Quintero still worries about bringing the virus home to her family and fears being in the same room with her grandmother. Quintero returns from work every day now, puts her clothes in a separate hamper and diligently washes her hands before she interacts with anyone.

The bills have been another constant worry. Quintero called the hospital and her insurance company and complained that she should not have to pay since she was seeking a test on her doctor’s orders. Neither budged, and the bills labeled “payment reminders” soon became “final notices.” She reluctantly agreed to pay $100 a month toward her balance — $50 to the hospital and $50 to the doctors.

“None of them wanted to work with me,” Quintero said. “I just have to give the first payment on each bill so they wouldn’t send me to collections.”

The Takeaway: If you suspect you have COVID-19 and need to isolate to protect vulnerable members of your household, call your local public health department. Most counties have isolation and quarantine programs, but these resources are not well known. You may be placed in a hotel, recreational vehicle or other type of housing while you wait out the infection period. You do not need to have a positive COVID test to qualify for these programs and can use these programs while you await your test result. But this is an area in which public health officials repeatedly offer clear guidance — 14 days of isolation — which most people find impossible to follow.

At this point in the pandemic, tests are more widely available and federal law is very clearly on your side: You should not be charged any cost sharing for a coronavirus test.

Be wary, though, if your doctor directs you to the emergency room for a COVID test, because any additional care you get there could come at a high price. Ask if there are any other testing sites available.

If you do find yourself with a big bill related to suspected COVID, push beyond a telephone call with your insurance company and file a formal appeal. If you feel comfortable, ask your employer’s human resources staff to argue on your behalf. Then, call the help line for your state insurance commissioner and file a separate appeal. Press insurers — and big companies that offer self-insured plans — to follow the spirit of the law, even if the letter of the law seems to let them off the hook.

Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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