Analysis for $ 12 thousand: an American received a huge medical bill for a simple procedure

Lorraine Rogge and her husband Michael travel the country by car. This is a common way of recreation for retirees. They spent several months this spring in Artesia, New Mexico. But things didn't turn out the way they expected. More details about the current situation were told by the publication NPR.

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In May, 60-year-old Rogge began to feel pain in the pelvic region. But in 2006 she had a complete hysterectomy, so the pain seemed unusual, especially since it lasted for several days. She found a local gynecologist who was part of her insurance plan.

The doctor asked if Rogge is sexually active, and she answered in the affirmative, specifying that she had been married for 26 years. Rogge decided that she had made it clear that she was in a monogamous relationship. The doctor then performed a pelvic examination and took a vaginal swab for laboratory examination.

The only laboratory test Rogge discussed with the doctor was to find out if she had a fungal infection. She was not given any medication for pelvic pain and eventually disappeared on her own after a few days.

Then the bill came.

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The medical center billed $ 12 for testing for vaginosis, vaginitis, and sexually transmitted infections. The insurer paid out $ 386.93 and $ 4161.58. The total outstanding invoice for analyzes was $ 7172.05. Rogge also paid $ 3010.47 to see a doctor.

What happened

Rogge didn't know two things when she sought medical attention. Firstly, Carlsbad Medical Center is known for its high prices and aggressive billing practices, and secondly, it did not expect to be screened for a wide range of sexually transmitted infections.

The latter worried her greatly, since she had sex only with her husband. She does not even remember being advised to get tested for sexually transmitted diseases. She was also not asked about whether she or her husband had sex with other partners, which would justify more testing.

“I was outraged that they did these tests because they told her they were going to test for a fungal infection,” Rogge says. “They did tests that were more relevant to young people who had multiple partners, rather than a 60-year-old grandmother who had been married for 26 years.”

“Although a doctor does not need a patient's permission to perform tests, doing so without informing the patient is not a good practice,” says Dr. Inna Park, an assistant professor of family medicine at the University of California, San Francisco School of Medicine. “This is especially true for tests for sexually transmitted diseases.” This is doubly true when these tests will cost thousands of dollars.”

Park, an expert on sexually transmitted infections, questioned the need for a complete set of tests for a patient undergoing a hysterectomy.

In addition, the cost of these tests was extremely high. “Vaginitis screening should not cost $12,” Park said.

Charles Ruth, a laboratory billing expert, agrees with her.

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“Frankly, retail prices for tests are ridiculous; they have no logic,” says Ruth.

In the fall of 2019, The New York Times and CNN investigated the Carlsbad Medical Center and found that the institution was suing thousands of patients for unpaid hospital bills. This medical center has higher prices than the rest. In 2019, a Rand Corp study found that private insurance companies paid Carlsbad Medical Center 505% of what Medicare would pay for the same services.

Included with Rogge's tests was the Quest Diagnostics SureSwab Vaginosis Panel Plus. It included six types of tests. The insurer did not cover the cost of the comprehensive tests, but Kim Gorode, a company spokesman, says that if the tests were ordered directly through Quest and not through the hospital, it is likely “in arrears the patient would be much smaller. "

Medicare would only pay labs about $ 40 for each test, according to figures provided by Russell Tole, superintendent of the New Mexico insurance division.

But hospitals and clinics charge significant markups on clinical tests sent to commercial labs.

Although private health insurance usually does not pay Medicare or Medicaid rates, Ruth says, private insurance reimbursement rates rarely exceed 200–300% of Medicare rates. Based on a 300% reimbursement rate, the total for six tests would be $ 720.

Tole, who has studied Rogge's account, calls the prices "outrageous."

What was decided

Rogge contacted Anthem Blue Cross and consulted with a customer service representative. After that, she filed a lawsuit for fraud and waste, as well as an appeal, in which she argued that the rates were excessive.

Her appeal was denied. Anthem Blue Cross told Rogge that, according to her plan, the insurance company paid the amount for which she was responsible and that, based on her deductible and the amount insured, she is responsible for the remainder.

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Anthem Blue Cross said in a statement that all Rogge tests were approved and "paid for at Anthem's pre-set rate with Carlsbad Medical Center."

By the time Rogge's appeal was dismissed, she had received a notice from the hospital that her bill would be sent to a collection agency if she did not pay the balance of $ 3.

Fearing the possibility of a lawsuit or bad credit, Rogge agreed to pay the bill within three years. She made three payments of $ 83,63 each in September, October and November, totaling $ 250,89.

Following a phone call and an email from Kaiser Health, the medical center called Rogge on November 20 and informed him that the balance would be canceled.

Conclusions

When visiting a doctor with whom you don't have a long-term relationship of trust, don't be afraid to ask how much the test will cost. Also ask what exactly you are testing for. Do not pay attention to the status of the doctor or medical institution. You may still be in debt.

If it is a blood test that will be sent to a commercial laboratory anyway, such as Quest Diagnostics, ask your doctor for a referral to donate blood right in the laboratory. This way you avoid extra charges. Obviously, this advice is not appropriate for a vaginal swab taken from a doctor's office.

Patients should always challenge bills that they feel are excessive and follow through if necessary.

Rogge started with her insurance company, like most patients who have a billing question. But she learned that in American medicine, what is legal and compliant with insurance can be logically absurd. However, if you are not satisfied with your initial requests, please keep in mind the options for further consideration of your complaints.

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Every state and US has a department that regulates the insurance industry. In New Mexico, this is the Insurance Control Office. Consumers can find their state department at website of the National Association of Insurance Commissioners.

Tole, insurance superintendent for New Mexico, said his office had no authority to tell the hospital that its prices were too high. But he is entitled to examine the account if a complaint is filed with his office.

“If a patient wishes, they can request an independent review to have the bill go to an independent organization that can verify whether it was medically necessary,” explains Toal.

In this case, it was not necessary because Rogge's account was canceled. After being contacted by KHN representatives, Melissa Suggs, a spokeswoman for the Carlsbad Medical Center, said the institution was reviewing the cost of its laboratory services.

“In the future, prices for these services will be lower,” the statement said.

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