Risha Ahmed was on cloud nine.
It was January, and Ahmed was at the OB-GYN’s office near his home in Venus, Texas, for his first prenatal check-up. After an ultrasound, anti-nausea medication and discussion of her pregnancy care plan, she said a nurse made a helpful suggestion.
The lab was located at Texas Health Hospital Mansfield, which opened in December 2020 in suburban Dallas-Fort Worth. Ahmed, who is just eight weeks pregnant, said the doctor told her everything about the visit was normal. “Nothing really stood out,” Ahmed said. “And of course there’s just a lot of excitement, and I really haven’t thought twice about anything.”
Her blood tests checked for multiple sexually transmitted infections, blood type and various hormones. Within days, Ahmed started bleeding and his excitement turned to fear. A repeat ultrasound in early February revealed no fetus.
“My heart just kind of broke at that point because I knew exactly what that meant,” she said.
She would have a miscarriage.
Then came the bills.
The patient. Risha Ahmed, 32, has an Anthem Blue Cross and Blue Shield policy through her employer.
Medical services. Analysis of Pap smear results and several blood tests in conjunction with Ahmed’s initial prenatal visit, including a complete blood count, blood type, and STDs such as hepatitis B, syphilis, and HIV.
Service provider. Ahmed received his tests at Texas Health Mansfield, a tax-exempt hospital jointly operated by Texas Health Resources, a faith-based nonprofit health system, and AdventHealth, another faith-based nonprofit.
General account. The hospital billed $9,520.02 for blood tests and pathology services. The insurer negotiated it down to $6,700.50 and then paid $4,310.38, leaving Ahmed with a $2,390.12 lab bill.
What does it give? Ahmed’s situation highlights how hospital laboratories often charge high prices for tests. Even when providers are in network, a patient can pay thousands of dollars for common blood tests that are much cheaper in other settings. Research shows that hospitals typically charge much more than doctors’ offices or independent commercial labs for the same tests.
The situation was particularly difficult for Ahmed because she had lost her pregnancy.
“Mentally, emotionally, physically coming to terms with it, dealing with the aftermath of the miscarriage, and then having to muster up the courage to then start calling your insurance, and the billing department, the provider’s office, trying to fight back. an account that you don’t feel that they sent you correctly, it’s just too much,” he said.
In Texas, the same lab tests were at least six times more expensive in a hospital than in a doctor’s office, according to a study by the Institute for Health Care Costs, a nonprofit organization that studies health care costs.
The designation may be even higher depending on the test. HCCI data, based on 2019 prices, show that the average price for a complete blood count in Texas was $6.34 at an independent laboratory and $58.22 at a hospital. Texas Health charged Ahmed $206.69 for that test alone.
“It’s convenient to have your lab done in the same building,” says Jessica Chang, senior research fellow at HCCI, but “many patients don’t think about how high the lab tests are.” Chang said he doubts many hospitals are recouping their overall costs when they pay insurance.
Anthem also billed Ahmed for at least four tests that most insurance plans would consider preventive care and therefore reimburse patients for free under the Affordable Care Act’s requirements to provide preventive care that includes aspects of prenatal care. Her EOBs, or “explanation of benefits” notices, show she paid out of pocket for a test that revealed her Rh factor, which detects a protein on the surface of red blood cells, as well as hepatitis B, hepatitis C for tests. and syphilis.
Asked to review Ahmed’s tests, Anthem spokeswoman Emily Snooks wrote in an email to KFF Health News that the claims “were presented as diagnostic, not preventive, and were paid according to the member’s health plan benefits.”
There should be “absolutely no out-of-pocket costs” for those screenings, said Sabrina Corlette, co-director of Georgetown University’s Center for Health Insurance Reform.
The Centers for Disease Control and Prevention recommends screening pregnant women for several infectious diseases that pose a high risk during pregnancy. Ina Park, a professor of family and community medicine at the University of California, San Francisco, and an expert on sexually transmitted infections, said the tests Ahmed received did not raise any red flags from a clinical perspective. “It’s really more than what the actual lab would charge based on the actual cost of the tests,” Park said. “This is indeed too great a price.”
For example, Ahmed paid $71.86 in coinsurance for a hepatitis B test for which the hospital billed $418.55. The hospital charged $295.52 for the diagnosis of syphilis. it cost him $50.74 out of pocket.
“Just wondering, is the insurance company really negotiating with this provider as aggressively as they need to in order to keep the reimbursement reasonable?” Corlette said:
The resolution. Ahmed refused to pay the bills, and Texas Health sent the debt to collections. When she tried to get answers about the costs, she said she was bounced back and forth between the doctor’s office and the hospital’s billing department. Ahmed filed a complaint with the Texas Attorney General’s Office, which forwarded it to the Texas Health and Human Services Commission. He never listened.
According to Ahmed, a hospital representative suggested that her blood work might be coded incorrectly and agreed that the charges were “really unusually high,” but she was told there was nothing the hospital could do to change them. The hospital did not comment on the reason for the high charge. And in a March 7 email, an AdventHealth employee told Ahmed that the doctor’s office had “no control” over the hospital’s billing.
Ahmed filed a complaint with Anthem, but it was denied. The insurance company said the claims were properly processed under its benefits, which cover 80% of what the insurer agrees to pay for in-network lab services after it has met its deductibles. Ahmed has a $1,400 deductible and a $4,600 maximum for in-network providers.
“We depend on health care providers to submit accurate billing information about what medical care is needed and provided,” Snooks said. Asked about the Texas Health Lab’s reimbursements, he added: “The claim was reimbursed based on the laboratory’s contract with the health plan.”
After a KFF Health News reporter contacted Texas Health on Oct. 9, the hospital called Ahmed on Oct. 10 and said it would zero out his bills and remove the charges from collections. Ahmed was relieved, “like a huge burden has just been lifted off my shoulders.”
“It’s been 10 months of fighting it and it’s finally gone,” he said.
Texas Health Resources and AdventHealth declined to answer detailed questions about Ahmed’s allegations and the tests he was ordered to receive.
“We are sorry that Mrs. Ahmed did not get clarity with us about her care. Our priority is to provide our patients with safe, effective and medically appropriate care,” hospital spokeswoman Laura Shea said in an emailed statement.
Acceptance. Ahmed’s problem illustrates the pitfalls of using a hospital laboratory for routine testing.
For standard blood work, “it’s really hard to argue that there’s a difference in quality” between independent labs and hospitals, which warrants higher prices, Chang said. This is also true for other services such as images. “There is nothing special about the machines that hospitals use for CT or MRI scans. It’s the same device.”
In general, state and federal legislators are paying attention to this issue. Congress is considering legislation that would equalize payments for certain services whether they are provided in a hospital outpatient department or in a doctor’s office, though not laboratory services. Hospitals have tried to steer clear of such policies, known as “site-neutral payments.”
For example, the Lower Costs, More Transparency Act would require the same prices under Medicare for physician-administered drugs, whether they are dispensed in a doctor’s office or outside a hospital in an outpatient department. That bill would also require labs to disclose the prices they charge for Medicare tests. Another bill, the bipartisan Primary Care and Health Workforce Act, would bar hospitals from charging commercial health plans certain facility fees they use to cover operational or administrative costs.
According to the National Conference of State Legislatures, Colorado, Connecticut, Ohio, New York and Texas have limited the ability of providers to charge facility fees to privately insured patients for certain services. Colorado, Connecticut, Maryland, and New York require health care facilities to disclose the facility’s fees to patients providing care; Florida has similar requirements for independent emergency departments.
Patients should keep copies of itemized bills and insurance statements. Although not the only evidence, these documents can help patients avoid the costs of recommended preventive screenings.
For now, patients can actively avoid such extreme bills. When your doctor says you need blood tests, have the request sent to a commercial lab like Labcorp or Quest Diagnostics that’s in your network and have the tests done there. If they can’t do it electronically, ask for a paper claim.
“Don’t always go to the lab your doctor recommends,” Corlette said.
KFF Health Newsformerly known as Kaiser Health News (KHN), is a national news outlet that produces in-depth journalism on health issues and is one of the major operating programs. KFF: — an independent source of health policy research, polling and journalism.
Emmarie Huetman 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.
Copyright 2023 KFF Health News. To see more, visit KFF Health News.
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