Article Summary: People with COVID-19 symptoms in March and April were often billed for expensive scans and bloodwork because they didn’t qualify due to strict testing criteria.
By Julie Appleby, KHN, Jul 07, 2020.
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.
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.”
Article link: https://khn.org/news/covid-catch-22-they-got-a-big-er-bill-
because-hospitals-couldnt-test-for-virus/