While it’s widely believed that coronavirus (Covid-19) testing is supposed to be covered with no patient out-of-pocket payments by federal law in many cases, we have learned increasingly that Insurers are declining to pay.
While we haven’t seen a flood of such reports, there are plenty. We’ve investigated a few, and found that in several cases — three of the four — our questions to the insurer, the provider, or both have resulted in what appear to be satisfactory resolutions: The people in question don’t have to pay for testing.
The law is quite clear, said Sabrina Corlette, a Georgetown University professor who studies insurance and the health care system. If it’s “in a clinical setting, screened by a professional, with symptoms, the fully insured plans absolutely have to cover,” she said. Self-insured companies are different, and as many as 55 to 60 percent of insurance plans are self-insured — so that story remains to be told.
Coverage for uninsured people is also not as clear-cut. Federal law makes available a pot of money that providers are supposed to be able to use to pay for testing under the Families First Coronavirus Response Act or FFCRA; the Paycheck Protection Program and Health Care Enhancement Act or PPPHCEA; and the Coronavirus Aid, Relief, and Economic Security (CARES) Act. But It’s not clear that all hospitals and other providers know about that or are using it, because we are hearing that uninsured people are getting bills.
Here are several case studies. These are not the only ones we’ve heard, but these four people agreed to go on the record and showed me bills, and spent time with me to explain what happened.
The data scientist in Colorado
Alex Goodman, 29, had some trouble sleeping due to breathing problems. Suspecting that he might be experiencing Covid-19 symptoms, he went to an urgent care center on April 22, and his heart rate and blood pressure were found to be elevated. The urgent care center sent him to UC Health Poudre Valley Hospital in Fort Collins, because the only other place in the state where he could get tested was an hour away by car, and the urgent care center told him only a hospital would be able to rule out symptoms of Covid or a pulmonary embolism, which he had had several years before. He agreed to the E.R. visit and drove there himself.
The visit lasted about 90 minutes, he said, and included Covid testing and other assessments to rule out a pulmonary embolism because of his medical history. Goodman is a data scientist at the NASA Jet Propulsion Laboratory in Pasadena, Calif., and lives and works in Colorado under a full-time telecommuting arrangement that predates the pandemic.
After he left, he asked the hospital for a bill, which he said totaled about $6,000, and then another bill arrived for the emergency room doctor, who is not a hospital employee, for $650. His responsibility, his insurer told him, would be around $3,000.
Goodman posted about his issues on Reddit. When we talked to him, he said the insurance company told him that he was indeed responsible for the hospital bill — and then reversed course and said he would not have to pay that, though the urgent care bill and the doctor’s bill would have to be considered separately.
“Note that in my case, my ER doctor noted ‘suspected’ COVID-19 in my notes. This would explain why according to Anthem, none of my providers used any COVID-19 codes when they initially sent the claims to them. Seems like a convenient excuse to force the insured patients to correct them in these cases, because they especially don’t like being responsible in the case where the tests come out negative like mine.”
We reached out to the UC Health media department to inquire, where Dan Weaver of the media department explained that Goodman never did get a bill. “I think he got an explanation of benefits from Anthem that suggested he might owe,” Weaver said. “An EOB is not the same as a bill. We have not sent out any bills to patients related to Covid.”
He said the laws saying patients wouldn’t have out-of-pocket responsibilities for Covid-related tests and treatments had resulted in “a lot of variation with how some of the insurance companies have interpreted those laws.”
For example, he said, correct coding might result in incorrect payments. A bill may be coded with first an emergency room visit, then shortness of breath, then severity of illness or cough or fever, and only later a Covid code, he explained.
“In some cases when we have processed these, we have found that the payers, in trying to determine if a patient is Covid-19, they are looking at the first three codes. And if they don’t see Covid in the top three, they might be inaccurately paid,” he added. “That might have been what happened in Alex’s case.” He added that the hospital billing department saw that Anthem “had either read or coded wrong,” and they reprocessed, with Anthem agreeing that the emergency room visit was Covid-related. “I believe he will have no patient obligation for that emergency room visit,” he said.
Why are the urgent care visit and the emergency room doctor’s bill not Covid-related then? He said those two separate bills are still under discussion. He also said the urgent care bill’s notes do not mention Covid, though Goodman is sure that was the reason he was sent to the E.R. (The urgent care center is also a UC Health facility, but the E.R. doc works for a separate, independent staffing agency, Emergency Physicians of the Rockies.),
A couple of days later, Weaver emailed to say “because he received a COVID-19 test at the ED, they’re considering the entire episode of care including the urgent care visit to be COVID-19 related. So I don’t think he’ll have a patient responsibility for his urgent care visit.”
The emergency room doctor’s bill is also under review, Weaver said.
Goodman wrote in an email: “Another perhaps interesting little tidbit I discovered just now: Apparently, official CDC guidelines state that COVID-19 specific codes for visits should only be used when the patient is confirmed or presumptive confirmed COVID-19 positive.” Here’s the link.
So it’s not impossible that “improper coding” will result in bills that aren’t paid properly.
Side note: If you’re keeping track at home, notice that the Emergency Physicians of the Rockies is paying for billing services from Reventics, which says it is “Improving revenues and decreasing costs using clinically led, technology driven provider solutions.”
The photographer in Virginia
Will Niccolls, 54, a photographer from Alexandria, Va., said he went to his Kaiser Permanente HMO with fever, shortness of breath, loss of smell and taste, and other typical Covid symptoms in April.
He said his doctor would not order a Covid test. “I pressed my doctor a little bit,” Niccolls said in a phone interview. “He pushed back that it was their policy.”
So on May 1, he went to All Care, a local Virginia urgent care center, where he was screened in a video visit and tested the same day, and told he was positive. He paid $125 out of pocket, and was contacted by the Virginia Department of Health for contact tracing. Five weeks later, he asked Kaiser to test him to make sure he had cleared the virus, and they refused, he said. So he went back for a second test at All Care later to prove that he had cleared the virus, and paid out of pocket for that one too.
“I can understand if Kaiser is trying to make the argument” against excessive testing, he said. “But public health professionals and smart people are saying that knowing who’s positive and who’s recovered is the only way we will be able to move forward.”
“I understand a doctor and patient may reasonably decide a test isn’t necessary as a matter of individual care. It probably doesn’t change the treatment, and it involves some risk because the patient has to leave the house and be close to medical staff,” he wrote in an email.
“But if a patient like me, with qualifying symptoms, wants a test, and tests are available, I don’t understand why they would refuse to order a test. On May 1, 2020, I scheduled a video doctor visit with a local for-profit clinic, AllCare, and got tested the same day a few miles from my house. This shows me test availability wasn’t a factor.”
To further confuse the issue, Niccolls sent an email that he received from Kaiser about Covid testing and treatment. The note says: “To alleviate costs and stress to members, and allow members to focus on getting well, we’re extending our waiver of all out-of-pocket costs for inpatient and outpatient services related to COVID-19 until December 31, 2020. Outpatient testing and diagnosis continue to be available at no cost. Remember, tests are only available with your doctor’s referral.”
In response to a request for comment on Niccolls’ complaint, Marisa Lavine of Kaiser Permanente’s public relations department said in an email:
“Out of respect for the privacy of our members and the requirements of HIPAA, we are unable to discuss specific details of care.
“Our COVID-19 testing practices have been based on CDC guidance, which has evolved over the past few months. Each request for COVID-19 testing is evaluated through a conversation between a physician and a patient. All patients are advised to contact us again if symptoms change. Currently, we are expanding COVID-19 diagnostic testing for members who are symptomatic, as well as certain asymptomatic members who are coming in for clinical procedures or who require testing for other reasons.
“Kaiser Permanente has waived all member out-of-pocket costs for screening, testing, and treatment of COVID-19-related inpatient and outpatient services through December 31, 2020. For members who meet the current criteria for COVID-19 testing, the cost of the test will be covered.”
We asked if the policy doesn’t apply to Niccolls and why. She wrote in an email: “I’m unable to comment on specific details of member care due to HIPAA. However, our COVID-19 testing practices have been based on CDC guidance, which has evolved over the past few months. For members who meet the current criteria for COVID-19 testing, the cost of the test will be covered.”
Niccolls said he was planning to file for reimbursement with Kaiser Permanente under their several-page-long process.
The financial services worker from Georgia
Matthew Atwood, 23, from Roswell, Ga., went to a local urgent care clinic in early March with a fever of 103 degrees and shortness of breath as well as other symptoms. He was told he needed to be tested. But the urgent care clinic did not have tests on site, and “they said they could give me antibiotics at urgent care, but it would be safer to get tested,” he said in an interview.
They sent him to the emergency room at Northside Hospital Forsyth in Cumming, Ga., said Atwood, who works at a boutique financial services company.
“I arrived where they hurried me back and ran several tests including the virus tests,” he explained in a social media post. “The nurses stated that, ‘I was a possible the virus patient’ and I went on the direction of the physician at Urgent Care who felt the same. Fortunately, I ended up just having a severe case of pneumonia, fever dehydration etc…,”
He got a bill from the hospital, including the Covid test — and a $27 tylenol — totaled $15,220.50, with his responsibility $2,400.
Atwood says he doesn’t think he is supposed to pay for Covid testing — but he wrote on social media that his insurer, Anthem Blue Cross and Blue Shield, says “because the diagnostic codes do not show the virus, there is no portion waivable thanks to Recent legislation. Hospital seems unwilling to negotiate.” The bill does indeed show that a Covid test was performed.
Atwood said in the phone interview that this was his first visit ever to a hospital and he’s stunned. “I honestly was under the impression that if I went there and tested positive, my whole bill would be covered,” he said. In early March, the president said ‘If you are feeling sick, go get tested.’”
“I would not have gone to the hospital if I’d known I was negative,” he added. “I would have taken antibiotics and go home. I honestly was really worried.”
The size of the bill shocked him, he said. That “$27 Tylenol? I could buy three bottles for that.”
Noting that a lot of the testing is not accurate — the respiratory tests have a lot of false negatives — he said he’s still not sure what happened. But the idea that he was supposed to go and take care of himself so as not to be a danger to his community was a motivating factor.
Now, he thinks about things differently.
“I am from the Southeast, and am generally fairly conservative,” he said. “I used to have this mindset that there’s not an issue with health care. Do not make poor choices, and you’ll be fine.
“But this is changing the way i think. It’s a racket when you charge $27 for a Tylenol.
“My voting choices will be more closely tied to health care than they were before, now that I have experienced this firsthand.
“I am fortunate enough to be able to pay this off in 4 months. I make too much to qualify for financial aid. But imagine that you make $32,000 a year, if you were in my shoes and in poverty, you would be looking at bankruptcy,”
I inquired at both the hospital and at Anthem. In the space of a few short hours, I got this response from Katharine Watson in the marketing and public relations department at Northside Hospital Healthcare System:
“Our Billing Department has spoken with both Mr. Atwood and his insurance company. BCBS is reprocessing the claim appropriately and has asked to allow 10 business days. At that time, we will follow-up with Mr. Atwood and this should be fully resolved.”
(Update: A few weeks later, Atwood emailed: “I apologize for the delay in communication but wanted to follow up with you to share some great news! Late last week I received word from Northside Forsyth Hospital that my new balance due is $0.00. I can only attribute this adjustment to the assistance that you provided me. I cannot express the gratitude for your efforts in lowering my financial burden. Based on the bill relative to my income this is truly trajectory altering and something I will be forever grateful for. I know I will have an opportunity to pay it forward and intend to do so. If there is any way I can assist regarding this issue or any other I will happily assist and forever be indebted to you and the aid that you offered. Thank you so much Jeanne!”)
The print shop manager in South Carolina
Matt Fram, a print shop manager in Myrtle Beach, S.C., went to Conway Medical Center in Conway, S.C., to get tested March 21. He and two co-workers suddenly got sick with Covid-like symptoms — headache, nausea, a “complete roller-coaster of symptoms” including better and worse days, for a week. So they went to the testing site in a tent outside the medical center.
Fram said he spent about a half-hour in the tent, and an adjacent tent. The hospital had no Covid tests, he said, but they tested him for flu and strep throat, both negative. But the hospital told him he tested positive for a viral infection which it could not identify. He was instructed to go self-quarantine for two weeks.
He later got a bill for $745 for the hospital’s services, and another $399 for a doctor — though he says he never saw a doctor.
Fram is uninsured. He said he expected a bill, but maybe a few hundred dollars — not $1,150.
His co-worker who is on his parents’ insurance is paying nothing.
Fram said he had alerted the hospital that they could get the claim covered under the FFCRA and CARES acts, sending them this link, but they did not waive his bill.
“The medical center where I went is now doing free testing,” he said in a phone interview. “It’s a kick in the gut that now, retroactively they are taking care of it.
“They encouraged me to get tested for the other things. And they put me under quarantine under suspicion that it could be that.”
He also said he never saw a doctor, only a nurse, and doesn’t know why he should be charged for seeing a doctor.
Staying out of work was the right thing, even without a firm diagnosis, he said, in part because a co-worker had just had a baby — making the public health reasons for testing and quarantining a very personal thing.
“I never entered a hospital,” he said. “I wasn’t seen by anybody but a nurse practitioner for 5 minutes. It seems like gouging And you put me on quarantine. I lost about 3 weeks worth of pay. And you have 60 days to pay them $1,200.”
Jeanne Pinder is the founder and CEO of ClearHealthCosts. She worked at The New York Times for almost 25 years as a reporter, editor and human resources executive, then volunteered for a buyout and founded ClearHealthCosts.
She was previously a fellow at the Tow Center for Digital Journalism at the Columbia University School of Journalism. ClearHealthCosts has won grants from the Tow-Knight Center for Entrepreneurial Journalism at the Craig Newmark Graduate School of Journalism at the City University of New York; the International Women’s Media Foundation; the John S. and James L. Knight Foundation with KQED public radio in San Francisco and KPCC in Los Angeles; the Lenfest Foundation in Philadelphia for a partnership with The Philadelphia Inquirer; and the New York State Health Foundation for a partnership with WNYC public radio/Gothamist in New York; and other honors.
Her TED talk about fixing health costs has surpassed 2 million views.