Fresh off a Caribbean cruise in early March, John Campbell developed a cough and fever of 104 levels. He went to his main care doctor and bought a flu take a look at, which got here up adverse.
Then issues bought unusual. Campbell mentioned the physician then turned to him and mentioned, “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 three, and nobody had an inkling but of simply how dangerous the COVID-19 pandemic would grow to be within the U.S.
At the JFK Medical Center close to his house in Boynton Beach, Florida, staffers met him in protecting gear, then ran a battery of exams — together with bloodwork, a chest X-ray and an electrocardiogram — earlier than sending him house. But as a result of he had not traveled to China — a number one criterion on the time for coronavirus testing — Campbell was not swabbed for the virus.
A $2,777 invoice for the emergency room go to got here the subsequent month.
Now Campbell, 52, is amongst those that say they have been wrongly billed for the prices related to looking for a COVID-19 analysis.
While most insurers have promised to cowl the prices of testing and associated companies — and Congress passed legislation in mid-March enshrining that requirement — there’s a catch: The law requires the waiver of affected person price sharing solely when a take a look at is ordered or administered.
And therein lies the issue. In the early weeks of the pandemic and thru mid-April in lots of locations, testing was typically restricted to these with particular signs or conditions, doubtless excluding hundreds of people that had milder circumstances of the virus or had not traveled abroad.
“They do pay for the test, but I didn’t have the test,” mentioned Campbell, who appealed the invoice to his insurer, Florida Blue. More on how that turned out later.
“These loopholes exist,” mentioned Wendell Potter, a former insurance coverage business government who’s now an business critic. “We’re just relying on these companies to act in good faith.”
Exacerbating the issue: Many of those sufferers have been directed to go to hospital emergency departments — the most costly place to get care — which can lead to large payments for patients-deductible insurance coverage.
Insurers say they totally cowl prices when sufferers are examined for the coronavirus, however what occurs with enrollees who sought a take a look at — however weren’t given one — is much less clear.
KHN requested 9 nationwide and regional insurers for specifics about how they’re dealing with these conditions.
Results were mixed. Three — UnitedHealthcare, Kaiser Permanente and Anthem — mentioned they do some degree of computerized evaluate of potential COVID-related claims from earlier within the pandemic, whereas a fourth, Quartz, mentioned it could examine and waive price sharing for suspected COVID sufferers if the member asks for a evaluate. Humana mentioned it’s reviewing claims made in early March, however solely these displaying confirmed or suspected COVID. Florida Blue, equally, mentioned it’s manually reviewing claims, however solely these involving COVID exams or diagnoses. The remaining insurers pointed to different efforts, reminiscent of routine audits that search for all types of errors, together with efforts to coach hospitals and medical doctors within the proper COVID billing codes to use to make sure sufferers aren’t incorrectly hit with price sharing. Those have been 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 9 mentioned sufferers ought to attain out to them or enchantment a declare if they think an error.
To be certain, it could be a fancy effort for insurers to return over claims from March and April, on the lookout for sufferers which may qualify for a extra beneficiant interpretation of the price waiver as a result of they have been unable to get a coronavirus take a look at. And there’s nothing within the CARES Act handed by Congress — or subsequent steerage from regulatory companies — about what to do in such conditions.
Still, insurers might evaluate claims, for instance, by on the lookout for sufferers who acquired chest X-rays, and diagnoses of pneumonia or excessive fever and cough, checking to see if any would possibly qualify as suspected COVID circumstances, even when they weren’t given a diagnostic take a look at, mentioned Potter.
One factor was clear from the responses: Much of the burden falls on sufferers who suppose they’ve been wrongly billed to name that to the eye of the insurer and the hospital, pressing care heart or physician’s workplace the place they have been handled.
John Campbell developed a cough and fever of 104 levels in early March, was directed to an ER and in the end acquired a $2,777 invoice for the go to. He is amongst those that say they have been wrongly billed for the prices related to looking for a COVID-19 analysis.
Some states have broader mandates that might be learn to require the waiver of price sharing even when a COVID take a look at was not ordered or administered, mentioned Sabrina Corlette, a analysis professor and co-director of the Center on Health Insurance Reforms at Georgetown University.
But regardless of the place you reside, she mentioned, sufferers who get payments they suppose are incorrect ought to contest them. “I’ve heard a lot of comments that claims are not coded properly,” mentioned Corlette. “Insurers and providers are on a learning curve. If you get a bill, ask for a review.”
Scarce Tests, Rampant Virus
In some locations, together with the state of Indiana, the city of Los Angeles and St. Louis County, Missouri, a take a look at is now provided to anybody who seeks one. Until not too long ago, exams have been scarce and primarily rationed, despite the fact that extra complete testing might have helped well being officers battle the epidemic.
But even within the early weeks, when Campbell and lots of others sought a analysis, insurers nationwide have been promising to cowl the price of testing and associated companies. That was good PR and good public well being: Removing price boundaries to testing means extra individuals will search care and thus might forestall others from being contaminated. Currently, nearly all of insurers providing job-based or Affordable Care Act insurance coverage say they’re totally waiving copays, deductibles and different charges for testing, so long as the claims are coded appropriately. (The regulation doesn’t require short-term plans to waive price sharing.) Some insurers have even promised to totally cowl the price of therapy for COVID, together with hospital care.
But getting caught with a large invoice has grow to be commonplace. “I only went in because I was really sick and I thought I had it,” mentioned Rayone Moyer, 63, of La Crosse, Wisconsin, who was additional involved as a result of 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 coverage community, complaining of physique aches and shortness of breath. Those signs might be COVID-related, however might additionally sign different circumstances. While there, she was given an array of exams, together with bloodwork, a chest X-ray and a CT scan.
She was billed in May: $2,421 by the hospital and greater than $350 in physician payments.
“My insurance applied the whole thing to my deductible,” she mentioned. “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 mentioned.
Quartz spokesperson Christina Ott mentioned sufferers with issues like Moyer’s ought to name the insurance coverage firm’s customer support quantity and ask for an appeals specialist. The insurer, she wrote in response to KHN’s survey of insurers, will waive price sharing for some members who sought a analysis.
“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 mentioned she has filed an enchantment and was notified by the insurer of a evaluate anticipated in mid-July. Back in Florida, Campbell filed an enchantment of his invoice with Florida Blue on April 22, however didn’t hear something till the day after a KHN reporter known as the insurer about his case in June.
Then, Campbell acquired cellphone calls from Florida Blue representatives. A supervisor apologized, saying the insurer mustn’t have billed him and that 100% of his prices can be lined.
“Basically they said, ‘We’ve changed our minds,’” mentioned Campbell. “Because I was there so early on, and the bill was coded incorrectly.”