When Kristy Uddin, 49, got her annual mammogram in Washington state last year, she thought she wouldn’t incur any costs because the test was guaranteed to be free under the 2010 Affordable Care Act. One of many preventive measures offered by patients. The ACA’s provisions make medical and economic sense and encourage Americans to use screening tools to nip medical problems in the bud and keep patients healthy.
So when Uddin, an occupational therapist familiar with the workings of the health care industry, received a $236 bill, he complained to his insurance company and the hospital. She even called for an independent review.
“I was like, ‘Tell me Why Did I receive this bill? Uddin recalled in an interview. The unsatisfactory explanation was that the mammogram itself was covered under the ACA, but the cost of the equipment and facilities was not.
The answer was particularly galling, she said, because a “free” mammogram she had a year ago at the same health system generated a bill for the radiologist’s exam of about $1,000. Although she fought the charge (and won), this time she threw in the towel and wrote a check for $236. But then she hurriedly submitted a submission to the KFF Health News-NPR “Bills of the Month” project:
“I was really angry – it was ridiculous,” she later recalled. “That’s not how the law is supposed to work.”
The designers of the ACA may have thought they had made it clear enough that millions of Americans would no longer have to pay for certain types of preventive care, including mammograms, colonoscopies, in addition to visits to the doctor to be screened for disease Check and recommend vaccines. But the law’s creators did not take into account America’s ever-innovating medical billing system.
Over the past few years, the healthcare industry has eroded the ACA’s guarantees, finding ways to bill patients in legal gray areas. Patients seeking preventive care, expecting their insurance to cover them in full, are hit with bills large and small.
The problem comes down to determining which components of medical malpractice are covered by the ACA guarantee. For example, during an annual preventive services visit, when does the conversation between physician and patient turn toward treatment? What screenings do patients need during their annual visits?
A healthy 30-year-old patient visiting a primary care setting may have some basic blood tests, while an overweight 50-year-old patient may need additional screening for type 2 diabetes.
To add to the confusion, the annual exam itself is “free” for women and those 65 and older, but this guarantee does not apply to men in the 18-64 age group – even though many preventive services require Medical visits (such as checking blood pressure or cholesterol and screening for substance abuse) yes cover.
It’s no wonder that what is covered under the prevention umbrella looks different to medical providers (trying to be thorough) and billers (intending to squeeze more dollars out of every medical encounter) than to insurance companies (who profit from a narrow definition) It looks very different.
For patients, the gray area has become a fee minefield. Here are some more examples gleaned from monthly billing items over the past six months:
Peter Opaskar, 46, of Texas, went to his primary care doctor last year for preventive care, just as he had done before, for free. This time, his insurance paid $130.81 for the visit, but he also received a puzzling bill for $111.81. Opaska learned he paid the extra fee because when his doctor asked him if he had any health issues, he mentioned he had digestive issues but had made an appointment with a gastroenterologist. Therefore, the office explained, his visit was billed as a preventive medical examination and consultation. “Next year,” Opask said in an interview, if someone asked him about his health, “even if I had a gunshot wound, I would say ‘no.'”
After getting coverage, Kevin Lin, a Virginia technologist in his 30s, went to a new primary care provider to take advantage of preventive care benefits; he didn’t have any medical problems. He said he was assured upon check-in that he would not be charged. His insurance paid for the $174 exam, but he was billed an additional $132.29 for a “new patient visit.” He said he had repeatedly called against the bill but so far had been unsuccessful.
Finally, Yoori Lee, 46, of Minnesota, a colorectal surgeon herself, was shocked when she received a $450 bill for a polyp biopsy during her first screening colonoscopy—something she knew A bill is illegal. Federal regulations released in 2022 clarifying the matter make it clear that biopsies during screening colonoscopies are included in the promise of no charge. “I mean, the whole purpose of screening is to find something,” she said, perhaps stating the obvious.
Although these patient bills defy common sense, the complex regulatory language surrounding the ACA provides room for creative development. Consider this from Ellen Montz, associate administrator and director of the Centers for Consumer Information and Insurance Oversight at the Centers for Medicare and Medicaid Services, in an email response to inquiries and interview requests on this topic: “If preventive services are not billed separately is tracked, or is not tracked as personal encounter data separate from the office visit, and the primary purpose of the office visit is not to provide preventive items or services, then the plan issuer may implement cost-sharing for the office visit.”
So, if the doctor decides that the stomach pain the patient mentions falls outside the scope of preventive care, can that visit be billed separately and the patient have to pay?
Montz also noted: “Whether a facility fee is allowed to be charged to a consumer depends on whether use of the facility is an integral part of performing a mammogram or any other preventive services required to perform a mammogram. Under federal law, no cost sharing is required.”
But wait, how do you get a mammogram or colonoscopy without the equipment?
Unfortunately, there is no federal enforcement mechanism to investigate individual billing abuse. And agencies’ remediation efforts were weak—simply instructing insurance companies to reprocess claims or notifying patients that they could resubmit their claims.
In the absence of stronger enforcement or remediation, CMS may curtail these practices and give patients the tools to fight back by providing the kind of clarity the agency provided years ago regarding polyp biopsies — more clearly Clarify what is included under the heading “Polyp Biopsy.” Preventative care, what can and cannot be billed.
The stories KFF Health News and NPR received may be just the tip of the iceberg. While each bill may be relatively small compared to the shocking $10,000 hospital bills that have become commonplace in the United States, the regrettable consequences are manifold. Patients pay bills they don’t owe, depriving them of cash they could use elsewhere. If they can’t pay, those bills may end up in the hands of debt collection agencies and ultimately hurt their credit scores.
Perhaps most disturbing: These unexpected bills may deter people from seeking potentially life-saving preventive screenings, which is why the ACA considers them an “essential health benefit” that should be free.
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