When public policy consultant Alexa Kasdan had what felt like a cold that wouldn't let up, she visited her doctor and underwent some seemingly simple tests—only to learn later that the episode generated a $28,395.50 bill, Richard Harris reports for NPR's "Shots."
When Kasdan visited her doctor, she'd had what she says felt like a cold and sore throat that had lasted for more than a week. Fearing she had strep throat, Kasdan booked an appointment with her primary care physician, Roya Fathollahi, at Manhattan Specialty Care. At the appointment, Kasdan gave a tube of blood and had her throat swabbed, and Fathollahi gave Kasdan a prescription for antibiotics, Harris reports.
But not long after the appointment, Kasdan received a message from her health insurer, Blue Cross and Blue Shield of Minnesota, telling her it was mailing her a check for $25,865.24 to pay for out-of-network lab testing. The original bill was $28,395.50, but the doctor's office said it would waive the portion that Kasdan would have had to pay out of pocket, which would have been $2,530.26, Harris reports.
"I thought it was a mistake," Kasdan said. "I thought maybe they meant $250. I couldn't fathom in what universe I would go to a doctor for a strep throat culture and some antibiotics and I would end up with a $25,000 bill."
It turned out the majority of the costs were for the throat swab, which Fathollahi's office had sent to an out-of-network lab, Harris reports.
The doctor's office told Kasdan the charges for the test were normal, but Kasdan told the office she would report them to New York's Office of Professional Medical Conduct, and she later reached out to NPR's and Kaiser Health News' Bill of the Month project regarding the charges.
A reporter working with the project eventually got in contact with Blue Cross and Blue Shield of Minnesota, and the insurer then stopped payment on the check and started investigating the charges.
Jim McManus, director of public relations for the insurer, said while the company usually has a way to flag excessive charges, "those necessary reviews did not happen in this case."
Kasdan, who said she was not told the throat swab was being sent out of network during her appointment, ended up paying a $25 copayment for the doctor's visit and a $9.61 fee to a lab for a different set of tests.
Can a throat swab be that expensive?
Why was Kasdan's throat swab so expensive?
According to Harris, Kasdan's doctor sent the throat swab for a "sophisticated smorgasbord" of tests that could detect a variety of viruses and bacteria.
Ranit Mishori, a professor of medicine at the Georgetown University School of Medicine, said the tests are usually used for patients in the ICU or patients with pneumonia. She said such testing was not warranted in Kasdan's case.
"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," Mishori explained, adding, "I have no idea why they were ordered."
Another reason Kasdan's bill was so high could be because her doctor sent the throat swab to an out-of-network lab, which could set its own prices for the tests. If the doctor had sent the swab to LabCorp, which is in Kasdan's health insurance network, LabCorp would have billed Kasdan's insurer about $650 for "all the ordered tests," the lab company said.
A third reason for the bill could be the relationship between the out-of-network lab and Kasdan's doctor's office. The bill showed Manhattan Gastroenterology, which has the same address and phone number as the doctor's office, provided the lab services.
Neither Fathollahi nor Shawn Khodadadian, CEO of Manhattan Gastroenterology, responded to "Shots'" request for comment.
In the end, Kasdan was not held responsible for the bill. However, while Kasdan wasn't financially responsible for the specific bill, billing practices like these increase the overall costs of medical care for consumers, Harris reports.
For instance, New York state law protects patients from so-called "surprise" medical bills by preventing health care providers and insurers from billing patients for out-of-network services without first getting patients' consent to do so. However, in such cases, out-of-network providers can still attempt to collect money from a patient's insurer. Those fees can drive up an insurer's overall costs, which in turn can lead the insurer to increase enrollees' premiums.
"She may not be paying anything on this particular claim," Richelle Marting, a lawyer who specializes in medical billing at the Forbes Law Group, said. "But overall, if the group's claims and costs rise, all the employees and spouses paying into the health plan may eventually be paying for the cost of this."
According to Marting, what happened to Kasdan is a common issue for insurers, because most claims are reviewed by computers. "There's never a human set of eyes that look at the bill and decide whether or not it gets paid" (Harris, "Shots," NPR, 12/23/19).