When Christy Udin, 49, went for her annual mammogram in Washington state last year, she was disappointed that the test was guaranteed to be free to patients under the Affordable Care Act of 2010. I thought it wouldn't cost anything because it's one of the preventive measures. The ACA's provisions made medical and economic sense and encouraged Americans to use screening tools that could nip medical problems in the bud and keep patients healthy.
So when the $236 bill arrived, Uddin, an occupational therapist who knows how the medical industry works, filed a complaint with the insurance company and the hospital. She also requested an independent review.
“It was like, 'Please tell me why I'm getting this bill,'” Uddin recalled in an interview. Unsatisfying explanation: Under the ACA, mammography itself was covered by insurance, but the cost of the equipment and facilities were not.
That answer was particularly upsetting, she says. A year earlier, a “free” mammogram she received at the same health system had resulted in a bill of about $1,000 for radiologist readings. Although she fought the charges (and she won), she now threw in the towel and cut a check for $236. But then she quickly started contributing to her KFF Health News-NPR “Bill of the Month” project.
“I was really pissed off. It's ridiculous,” she later recalled. “This is not the way the law is supposed to be.”
The designers of the ACA want millions of Americans to pay less for certain types of preventive care, such as mammograms, colonoscopies, and recommended vaccines, in addition to doctor visits for disease screening. You may have thought that you had made it clear enough that you would no longer have to pay. But the law's authors did not take into account America's ever-creative medical billing behemoth.
Over the past few years, the health care industry has sought ways to erode the ACA's guarantees and charge patients in the legal gray areas. Patients who receive preventive treatment expecting insurance to cover it in full are being blindsided by bills large and small.
The issue becomes determining exactly which elements of medical practice are covered by ACA coverage. For example, when does a conversation between a doctor and patient during an annual visit for preventive services veer into the realm of treatment? What screening is required at a patient's annual visit? mosquito?
A healthy 30-year-old who visits a primary care provider may have some basic blood tests, but an overweight 50-year-old may merit additional screening for type 2 diabetes. there is.
To further complicate matters, the annual health check itself is guaranteed to be “free” for women and those over 65, but that guarantee is not extended to men aged 18 to 64. is not applicable. Medical visits (such as blood pressure and cholesterol tests and drug abuse testing) are covered.
What is covered under the preventive umbrella is more important to health care providers (who are trying to be thorough) and billers (who are trying to be more thorough than they are to insurance companies (who benefit from a narrower definition) and from all medical practices). No wonder it can look very different for those looking to squeeze more money out of them.
For patients, the gray area is a billing minefield. Here are some more examples collected from the past six months of Bill of the Month projects.
Peter Opusker, 46, of Texas, went to his family doctor for preventive care last year. As before, it cost him nothing. This time, his insurance company paid him $130.81 for the visit, but he also received a mysterious bill of $111.81. Ms. Opaskal learned that additional charges had been incurred. The reason is that when the doctor asked him if he had any health concerns, he replied that he has digestive problems, but he had already made an appointment to see a gastroenterologist. Body. As such, the office explained that his visit was billed as both a preventive health check and a medical visit. Opuskar said in an interview that if asked about health concerns “next year,” “I would say no, even if I had a gunshot wound.”
Kevin Lin, a 30-something technology professional from Virginia, visited his new primary care provider to take advantage of preventive care benefits when he enrolled in insurance. He had no physical complaints. He said he was assured at check-in that he would not be charged. His insurance company paid him $174 for the test, but he was charged an additional $132.29 for a “new patient visit.” He has called repeatedly to oppose the bill, he said, without success so far.
Finally, Yuri Li, a 46-year-old from Minnesota who is also a colorectal surgeon, said she was issued a $450 bill for a polyp biopsy during her first colonoscopy. I was shocked because I knew that it was illegal. Federal regulations issued in 2022 to clarify this issue make it very clear that biopsies during screening colonoscopies are included in the free promise. “So the purpose of screening is to find something,” she said, perhaps not surprisingly.
Although these patient bills defy common sense, the complex regulatory language surrounding the ACA provides room for creative leverage. Ellen Monts, deputy administrator and director of the Center for Consumer Information and Insurance Oversight at the Centers for Medicare and Medicaid Services, said in an email response to questions and an interview request for this story: Let's think about this. Plan issuers may impose a visit cost burden if the visit occurs separately or is not tracked separately as visit data and the primary purpose of the visit is not to provide a preventive product or service. ”
So, if the doctor determines that what the patient mentioned about abdominal pain does not fall within the scope of preventive care, does that mean that that part of the consultation will be billed separately and the patient will have to pay?
And these are also Mr. Monts' words. “Whether it is permissible to charge consumers a facility fee depends on whether the use of the facility is an integral part of performing mammography or an integral part of other preventive services necessary for performing mammography. Depends on whether you are covered at no cost under federal law. ”
But wait. How can a mammogram or colonoscopy be performed without the equipment?
Unfortunately, there is no federal law enforcement mechanism to police individual billing fraud. And the agency's remedies are weak, merely instructing the insurance company to reprocess the claim or notifying the patient that the claim can be resubmitted.
In the absence of stronger enforcement or remedies, CMS has the tools to curb these practices and push back against patients, perhaps by providing clarity like the agency provided years ago regarding polyp biopsies. may be provided. Preventive medical care, what can and cannot be billed.
The stories KFF Health News and NPR receive are likely just the tip of the iceberg. And while each bill may be relatively small compared to his staggering $10,000 hospital bill that has become so familiar in the United States, the unfortunate consequences are wide-ranging. Patients pay bills they don't owe and are deprived of cash that could be spent elsewhere. If you can't pay, those bills will be turned over to debt collection agencies, which can ultimately negatively impact your credit score.
Perhaps most worryingly, these unexpected bills could deter people from getting potentially life-saving preventive tests, which is why the ACA mandated that these bills should be free. This is why it is considered an essential health benefit.
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(KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom producing in-depth journalism on health issues and one of KFF's core operating programs. is an independent source of health policy research, polling, and journalism.)
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