Coronavirus Tests Are Supposed to Be Free. The Surprise Bills Come Anyway.

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The New York Times is investigating the costs associated with testing and treatment for the coronavirus and how the pandemic is changing health care in America. You can read more about the project and submit your medical bills here.

Sarah Goldstone got a coronavirus test in Massachusetts after her health insurer said it was “waiving cost sharing for Covid-19 testing-related visits.”

Amanda Bowes, a health policy analyst in Maryland, got hers because she knew a new federal law should make coronavirus testing free for insured patients like her.

Kelly Daisley had one after seeing New York City’s ads offering free tests. “Do it for them,” says one bus shelter ad near her home, showing a happy family.

All three were surprised when their health insurers said that they were responsible for a significant chunk of their bills — in Ms. Daisley’s case, as much as $2,718.

“I had seen so many commercials saying there is testing everywhere, it’s free, you don’t need insurance,” said Ms. Daisley, 47, who was tested at an urgent care center three blocks from her Brooklyn apartment. “If I had to pay it off, it would clear out my savings.”

For months, Americans have been told not to worry about the costs of coronavirus tests, which are crucial to stopping the pandemic’s spread. “It is critical that Americans have peace of mind knowing that cost won’t be a barrier to testing during this national public health emergency,” Medicare’s administrator, Seema Verma, said in April.

Congress passed laws requiring insurers to pay for tests, and the Trump administration created a program to cover the bills of the uninsured. Cities and states set up no-cost testing sites.

Patients, whether with or without insurance, are beginning to find holes in those new coverage programs. Nationwide, people have been hit with unexpected fees and denied claims related to coronavirus tests, according to dozens of bills that The New York Times has reviewed. Insurers have told these patients they could owe from a few dollars to thousands.

These patients responded to a Times request for medical bills related to coronavirus testing and treatment, allowing us to identify previously unreported patterns in medical billing.

They are not alone. About 2.4 percent of coronavirus tests billed to insurers leave the patient responsible for some portion of payment, according to the health data firm Castlight. With 77 million tests performed so far, it could add up to hundreds of thousands of Americans who receive unexpected bills.

“Whether it’s through legislative action or public statements, Congress has made it really clear that there shouldn’t be cost sharing for Covid-19 testing,” said Julie Khani, president of the American Clinical Laboratory Association. “In practice, that’s not really the case.”

In some cases, the charges appear to violate new federal laws that aim to make coronavirus tests free for privately insured patients. In other cases, insurers are interpreting gray areas in these new rules in ways that work in their favor.

When asked about these charges, health plans say they are doing their best to follow the rules and cover all costs related to the testing. “If a claim is submitted with the proper coding to demonstrate that a test was given to diagnose Covid-19, or that a service was delivered to treat Covid-19, generally the claims for those tests and services are being covered at no cost to the patient,” said Kristine Grow, a spokeswoman for America’s Health Insurance Plans.

The insurers faulted the complexity of American medical billing, which can sometimes make it hard to tell when a coronavirus test is provided. Insurers can’t know to cover a claim differently if hospitals and doctor offices don’t use the right codes.

The new rules that Congress wrote midyear do not slot neatly into insurers’ billing systems. One health insurer said it was having to manually revise each claim for a coronavirus test, deleting the charges one by one.

“This is legitimately a confusing area, and the coding is all evolving,” said Christen Linke Young, a Brookings Institution fellow who helped write federal billing rules during her time at the Department of Health and Human Services. “Even if you’re an insurer or provider operating in good faith, and think you know what the rules are, figuring out how to identify relevant claims is a hurdle.”

Congress has legislated twice on coronavirus test billing. The Families First Coronavirus Response Act, passed in March, told insurers they could not charge co-payments or apply deductibles to coronavirus tests and other “items and services furnished” during the doctor visit. The rules apply to tests both to detect the disease and to those for antibodies.

The CARES Act built on those protections. It created rules for how to handle out-of-network coronavirus tests, telling insurers those, too, had to be covered at no cost to the patient. Insurers estimate that about 10 percent of coronavirus tests have been billed out of network so far, and that those tests tend to be more expensive than those in network.

Patients’ bills suggest that the rules aren’t always being followed. Insurers have, for example, applied co-payments and deductibles to the tests, claim documents show.

Ms. Bowes, from Maryland, was especially surprised to be charged a $50 co-payment for a coronavirus test at an urgent care center. She knew from her work as a health policy analyst for the National Association of Attorneys General that this wasn’t supposed to happen.

“I was really shocked when I got the bill,” she said. “It felt wrong, and I was angry especially because we were being billed before even receiving our results.” After protesting the fee to her insurer, the charge was reversed and covered.

Some patients found that insurance covered the test but denied payment for other services that went with it: another billing decision that could violate federal law.

One mother in California was surprised that her daughter’s coronavirus test was fully covered but that a $49 “after hours” fee was not — the clinic said it provided tests only in the evening, so as to not infect other patients.

Insurers have told some patients they are responsible for out-of-network charges, even though federal law appears to require insurers to at least partly cover them. This includes Ms. Goldstone from Massachusetts, who went for a test after experiencing mild coronavirus symptoms.

UnitedHealth paid $160 for her coronavirus test, but denied the $250 doctor visit that went with it, stating that her plan did not come with out-of-network benefits.

“It’s upsetting and demoralizing,” said Ms. Goldstone, a musician who has been largely out of work since the start of the pandemic. “I’ve spent months being careful with my finances, and already pay $266 a month for insurance.”

Federal law requires insurers to pay for any doctor visit associated with a coronavirus test, specifically noting that visits to urgent care centers are included. It is silent, however, on how much an insurer must pay to an out-of-network facility — although most experts agree a health plan would need to pay something rather than deny the fee.

“They shouldn’t be able to do that,” Ms. Young of Brookings said. “But I have sympathy for them and their claims system. It probably has rules that are saying: This person doesn’t have out-of-network coverage.”

UnitedHealth said it denied the charge because of how the urgent care center did its billing: It divided the coronavirus test and the visit into separate claims. After an inquiry from The Times, the insurer said it would reverse the bill and review how the urgent care center billed for its services.

“UnitedHealthcare is waiving cost share for Covid-19 testing, in accordance with state and federal guidelines, including the test Ms. Goldstone received,” a spokeswoman, Maria Gordon Shydlo, said. “She will not be responsible for the costs.”

Other bills present murkier situations. Ms. Daisley, from Brooklyn, had coronavirus diagnostic and antibody tests last month. She was surprised when she logged into her health insurance portal and saw four claims associated with her tests: one for each test, one for the doctor visit, and one for other tests she didn’t realize were being ordered.

Her insurance covered the visit and the diagnostic test. But it paid nothing for an antibody test and the other lab services, which were both sent off to out-of-network providers.

Experts say federal law requires the insurer to cover the antibody test in full, even out of network. But the rules around the other tests are less clear: The law states that insurers must cover services related to obtaining a coronavirus test but doesn’t identify what type of care makes the cut. Some providers seem to tack on unrelated lab tests. Patients at a drive-through coronavirus testing site in Texas, for example, were unknowingly tested for sexually transmitted diseases. Without clear federal guidance, insurers are left to sift through charges to decide what is related to coronavirus and what isn’t.

Initially, Ms. Daisley was left with more than $2,000 to pay to out-of-network labs: $210 for the antibody test and $2,508 for the other lab services. Her health plan, Anthem, denied the larger charge because her health benefits do not cover out-of-network care.

The insurer covered the charges after The Times inquired. “Seeing as Ms. Daisley was unaware the treating provider would send her samples to multiple out-of-network labs for what she understood was related to Covid testing, Anthem is covering the costs of the outstanding claims,” a spokeswoman for Anthem, Leslie Porras, said.

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