Bill Of The Month: Out-Of-Network Lab Ran Up Huge Tab For Sore Throat Tests : Shots - Health News A New York woman worried that her sore throat might be strep, so she went to the doctor to have it checked out. Then came the bill — with a price tag similar to a small SUV.
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For Her Head Cold, Insurer Coughed Up $25,865

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For Her Head Cold, Insurer Coughed Up $25,865

For Her Head Cold, Insurer Coughed Up $25,865

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DAVID GREENE, HOST:

Shocking medical bills can tell us a lot about dysfunction in our health care system, so each month NPR and Kaiser Health News take a look at an example. December's Bill of the Month starts with a simple cold and takes us on a roller coaster ride through dubious lab billing practices. NPR science correspondent Richard Harris has our story from New York City.

RICHARD HARRIS, BYLINE: There's no question that medical bills are often higher in expensive neighborhoods, and there's no question that this corner of New York City, not far from Gramercy Park, is one of the most expensive bits of real estate in the country. But still, you have to ask - if you go to a doctor with a cold and a sore throat, should you expect a lab bill that tops $28,000? That's what a doctor at Manhattan Specialty Care, just off Park Avenue South, charged Alexa Kasdan.

I caught up with this 40-year-old public policy consultant at an office uptown.

ALEXA KASDAN: I started getting a really sore throat, and so I decided just to go the doctor to see if I had strep throat. I was leaving on vacation that next week overseas, and so I just wanted to, like, have some antibiotics in case it didn't go away.

HARRIS: The appointment with Dr. Roya Fathollahi was quick, she says - a throat swab and a blood draw and she was out the door with her prescription. Her cold went away pretty quickly, and she enjoyed her vacation.

KASDAN: I get back about 10 days later. There's several messages on my phone, and I have an email from the billing department at Dr. Fathollahi's office.

HARRIS: They tell her that Blue Cross Blue Shield is mailing her family a check for more than $25,000 to cover some of the out-of-network lab tests. The actual bill was over $28,000, but the doctor says they won't collect the $2,500 copay.

KASDAN: I thought it was a mistake. I thought maybe they meant $250. I couldn't fathom in what universe I would go to the doctor for a strep throat culture and some antibiotics and I would end up with a $25,000 bill.

HARRIS: This is perfectly normal, the doctor's office kept assuring her, and they sent a courier over to her house to pick up the check. Did the doctor tell you what test she was running?

KASDAN: No.

HARRIS: Did she tell you that she was sending things to a clinician or a lab that was out of network?

KASDAN: No, definitely not.

HARRIS: And you went back and forth a little bit with the billing people, right? You made it clear that you were unhappy about this.

KASDAN: Yes, I made it very clear that I was unhappy about it.

HARRIS: In fact, she told them she would report the doctor to the New York State Medical Board. The tests in question turned out to be DNA probes that were looking for a smorgasbord of viruses and bacteria. Dr. Ranit Mishori, professor of family medicine at the Georgetown University School of Medicine, sees no reason to run them.

RANIT MISHORI: In my 20 years of being a doctor, I've never ordered any of these tests, let alone seen any one of my colleagues, students and other physicians order anything like that in the outpatient setting. I have no idea why they were ordered.

HARRIS: Maybe for a patient in the intensive care unit or with a difficult case of pneumonia there could be a reason to run these tests, she says. The ones for influenza are potentially useful, but there's a cheap rapid test that could have been used instead.

MISHORI: There are about 250 viruses that cause the symptoms for the common cold. And even if you did know that there was virus A versus virus B, it would make no difference because there's no treatment anyway.

HARRIS: So no reason to run these tests. Alexa Kasdan also wondered whether running these tests and running up her insurance bill is even legal. Richelle Marting, an attorney in Overland Park, Kan., who specializes in medical billing, says that depends on the details.

RICHELLE MARTING: There are a lot of state law issues that could be involved, and there's a lot of contractual issues that can be involved in this particular issue.

HARRIS: New York state has a surprise billing law. Patients need to be informed if their in-network doctor is referring a test to an out-of-network provider and to warn people that they could end up with a big bill. State laws also limit cozy relationships between doctors and labs. That could be at play here. Insurance companies also have contracts with doctors, say, making sure lab tests are done in network. But billing expert Marting says insurance companies aren't monitoring most claims as they come in.

MARTING: Most claims processing, even for something - a claim like this that you and I would read it after the fact and think, gosh, this just seems outrageous to pay this much money for these types of lab services - are often completely automated. There's never a human set of eyes that look at the bill and decide whether or not it gets paid.

HARRIS: The list prices in this case are about 20 times the going rate in that Manhattan ZIP code, Marting says. And if the throat swab had been sent to LabCorp, which is in network for Kasdan, LabCorp says it would have charged the insurer about $650 rather than the more than $28,000 for essentially the same tests. Dr. Fathollahi did not respond to requests for comment. And even though Alexa Kasdan didn't have to pay, practices like this still cost us, Marting says.

MARTING: She may not be paying anything on this particular claim. But overall, if the group's claims and costs rise, everyone - all the employees and their spouses paying into the health plan may eventually be paying for the cost of this.

HARRIS: After we started asking questions about this, Kasdan's carrier, Blue Cross Blue Shield of Minnesota, launched an investigation. They acknowledged that their review process failed to flag this extraordinary bill. They said the doctor's office had not cashed the check, so they put a stop payment on it while they dig deeper. Marting says people can take issues like this to their insurance company or state regulators or do some of their own legwork before leaving the doctor's office.

MARTING: I always ask where they're sending my labs or where they're sending my images so that I can make sure that that's in network with my health insurance company.

HARRIS: Doctor Mishori at Georgetown suggests taking an active role in your medical care.

MISHORI: It is OK to ask your doctor - why are you ordering these tests, and how are they going to help you come up with a treatment plan for me? And I think this is important for patients to be empowered and ask these questions rather than be faced with unnecessary testing, unnecessary treatment and, in this case, also outrageous billing.

HARRIS: And what did the $28,000 test reveal about the cause of Kasdan's sore throat? Not a thing, she says.

KASDAN: Everything was negative.

HARRIS: Richard Harris, NPR News.

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