Leah Cox did not intend on getting tested for the new coronavirus. That’s not why she went to see a Tucson ear, nose and throat doctor.
She had been feeling ill for several weeks and just wanted to figure out why.
She was short of breath and had been for nearly a week. That is what alerted the doctor that she might be infected.
She didn’t particularly want to get tested, but the doctor urged her to. He stuck a swab in her nose, farther back than she knew was possible.
Afterward, the doctor’s office told her the test would cost her $125. She questioned the charge. “I thought it was supposed to be free or nearly free. I don’t understand,” she said. “And they said, ‘No, it’s not.’”
She asked Valley Ear Nose and Throat to bill her insurance first, but they wouldn’t, she said. She asked if she needed to pay before she left. They said “no,” she said.
On her drive home, however, the doctor’s office called and told her the lab wouldn’t test her sample without payment upfront.
At this point, her options felt limited. She was already making plans to quarantine herself as she waited to learn if she was infected. She would send her kids to her ex-husband’s house for a couple of days.
If she was infected with the new coronavirus, at least she would know why she felt ill. She almost hoped the result would be positive, just to have answers.
She had gone to the doctor to see if her illness was an allergic reaction. But maybe this test would explain everything. “So yeah, let’s take the test so we can figure that out,” she said.
She paid for the test over the phone with her credit card.
About a day later, the results came in. Negative. She was not infected.
Loopholes in coverage for virus testing
Congress moved to cover coronavirus testing for everyone by passing government relief packages that were signed into law on March 18 and March 27. But neither insured nor uninsured patients are fully protected from having to pay for a test.
The relief package signed into law on March 18, known as the Families First Coronavirus Response Act, gives states the option to expand Medicaid coverage to the uninsured for coronavirus testing. Arizona’s plan to do so has been approved by the federal government, but it hasn’t been implemented yet.
For insured patients, the same law required insurance companies to cover coronavirus testing without passing along any cost-sharing charges to patients. These types of charges include copayments and deductibles, but do not include premiums.
This first law didn’t protect patients from “surprise billing,” which happens when insurance companies pay only part of an out-of-network charge, leaving the patient to pay the difference.
But the Coronavirus Aid, Relief, and Economic Security Act signed into law on March 27 moved to patch this loophole by requiring insurance companies to cover out-of-network testing charges in full.
Even so, neither of these laws protected Cox, and patients like her, from being billed for her coronavirus test. The lab that tested her sample, MiroGen DX, charged her directly and required the money upfront.
The coronavirus relief packages do not prohibit out-of-network labs from billing insured patients directly, Karen Pollitz, a senior fellow at the Kaiser Family Foundation, said in an email.
The law, known as the CARES Act, required providers to list the price of their tests on their websites. If they don’t, they may face fines of up to $300 a day.
It’s unusual to require providers to post prices in a prominent way so patients can compare prices, said Tara Sklar, a professor of health law at the University of Arizona.
It shows that we can have a much more “transparent, standardized, and fair” health-care system in the United States, she said in an email. One where patients can price-shop before agreeing to a test or treatment.
In practice, however, Cox didn’t have much use for these newly listed prices.
“The lab website had something about testing being like $99. But I mean, when I went into the ENT, I wasn’t looking for a test and I didn’t know what lab they were sending it to,” she said. “So that wouldn’t have really been helpful upfront.”
On April 1, MicroGen DX dropped its listed price from $125 to $99 for patients, said Rick Martin, the lab’s CEO.
The price is relatively easy to find on MicroGen DX’s website. It only takes one click and a couple scrolls.
After the fact, Cox searched for prices elsewhere. But the requirement to list prices doesn’t mean it’s always easy to find them.
“LabCorp made it very hard to find the cost,” she said in a text. “Sonora Quest was a little easier.”
CEO explains why he billed Cox
The reason MicroGen DX billed Cox directly is, at its root, an issue of trust. Martin doesn’t trust insurance companies to pay him for the coronavirus test, even though the CARES Act requires them to do so, he said in a text. “They have never paid us unless the patient has a top-tier plan.”
Martin files private insurance claims for tests other than those that detect the new coronavirus, but he can’t afford not to get paid for coronavirus tests because the volume is so high, he added.
CEOs of smaller labs, like Martin, feel that the agreements between bigger labs and the insurance companies have largely boxed them out of the insurance networks. And as out-of-network labs, it’s hard for them to get paid when they file private insurance claims.
The types of agreements that these CEOs are describing are not uncommon, said Sklar, the UA health law professor. “There are entire courses on this topic.”
Sonora Quest, for example, does negotiate exclusive laboratory contracts, said Jessica Pridonoff, a spokeswoman for the lab, which is a joint venture between Banner Health and Quest Diagnostics, although it’s independently run.
Some insurance companies prefer using one laboratory for their network, she said, adding that these contracts provide patients with convenient access to care across the entire state.
“It’s this underbelly of the business that patients would never see,” said Tootie Tatum, the CEO of Blackhawk Genomics, a laboratory consultant company that works with 70 to 80 smaller labs a year, including MicroGen DX.
At a time of huge demand for coronavirus tests, labs she works with are processing these tests at well below their capacity because it’s difficult for them to compete in an industry with these existing business dealings, she said.
Big lab companies like LabCorp and Quest Diagnostics have a monopoly on becoming in-network providers, said Trey Fluitt, CEO of Specialty Drug Testing, a lab in Louisiana that tests for the new coronavirus.
But unlike Martin, Fluitt has placed more hope in the CARES Act, which requires insurance companies to cover out-of-network testing. Since he doesn’t charge patients upfront, this could mean the difference between staying open or shuttering his business, he said. “It’s really too early to tell.”
Looking for Cox’s money
Cox didn’t know if she could get her money back. And she was feeling too sick to try. Her focus has been on treating her illness for the last week and a half.
After the Arizona Daily Star contacted the doctor’s office where she was tested, the lab that processed her sample and her insurance company, Cox is somewhat closer to getting her money back but still has unanswered questions.
Just because a provider like MicroGen DX bills a patient, that doesn’t mean the patient is responsible for paying those charges, Sklar said.
Pollitz, of the Kaiser Family Foundation, had an idea of how Cox could get her money back but warned it could be a challenging process, even if Cox wasn’t responsible for the charge.
First, Cox needed to ask her insurance company to cover the bill. From there, Pollitz wasn’t sure if the lab would refund her money or if the insurance company would reimburse her.
Martin said the insurance company would need to reimburse her. Cox already paid for the test, so there was no need for MicroGen DX to file such a claim asking her insurance company to pay.
Cox has a Meritain Health insurance plan, which is an Aetna company. The Arizona Daily Star shared a copy of Cox’s receipt for the test with a spokeswoman for Aetna.
Off the bat, the spokeswoman pointed out that MicroGen DX had not filed a claim. Then she confirmed that Cox could submit the claim herself.
Once Aetna receives a claim and confirms the test was ordered by a physician, they would reimburse her the $125, Shelly Bendit, the spokeswoman, said in an email.
But Cox doesn’t know how to file a claim. “Honestly, what I’d probably do is I’d have to putz around on their website to figure out how.”
And she also doesn’t know how to prove to her insurance that the doctor ordered her test. “It’s not like he wrote something down or did a referral or something,” she said. “He did it right there in the office.”
Bendit declined to answer questions about how Cox could prove a physician ordered her test but did say someone from the company would follow up with Cox to help her through the process.
The law doesn’t require a physician’s order to get tested, but it specifically covers tests ordered by a health-care provider.
For some physicians, Martin’s upfront charges wouldn’t be ideal.
At Escalera Health in Tucson, for example, few of Dr. Christian Moher’s patients would be able to pay $125 without being sure they could recoup their money, he said.
For patients looking to get tested, most places require a physician’s order, Pollitz said.
Ultimately, a patient’s health-care provider will decide if a test is appropriate.
Testing supplies are still limited. The Arizona Department of Health and Safety is giving certain people first dibs. Patients hospitalized with respiratory symptoms are given priority. So are health-care workers, first responders and critical infrastructure personnel who have symptoms. People living in nursing homes or other “congregate settings” are also prioritized. And health-care providers may turn patients away from getting tested if they are not sick enough.
Cox’s experience is an example of the out-of-network dilemma in which patients can find themselves, at no fault of their own, amid the pandemic, health law professor Sklar said.
“Ask for an itemized medical bill, whenever you receive a medical bill, to run it by your insurer to see what they cover, what they don’t cover,” she said. “It goes a long way.”
Contact reporter Alex Devoid at firstname.lastname@example.org or 573-4417.
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