Why the cost of a routine blood test depends on where you get it: Injections

Reesha Ahmed is on cloud nine.

It was January, and Ahmed was having her first prenatal visit at an OB-GYN office near her home in Venus, Texas. After getting an ultrasound, taking anti-nausea medication and discussing her pregnancy care plan, a nurse made a handy suggestion: Go to the lab down the hall for standard testing, she said.

The lab is located within Texas Health Mansfield Hospital, which opened in December 2020 in the Dallas-Fort Worth suburb. Ahmed, who is only eight weeks pregnant, said her doctor told her everything about the checkup was routine. “Nothing really stands out,” Ahmed said. “Of course, there was a lot of excitement, so I really didn’t think too much about anything.”

Her blood tests checked for multiple sexually transmitted infections, blood type and various hormones. Within days, Ahmed began bleeding and his excitement turned to fear. A repeat ultrasound in early February showed no fetus.

“My heart broke at that moment because I knew exactly what it meant,” she said.

She will have a miscarriage.

Then the bill came.

patient: Reesha Ahmed, 32, has an Anthem Blue Cross and Blue Shield policy through her employer.

medical service: At the same time as Ahmed’s first prenatal visit, the Pap smear results and multiple blood tests were analyzed, including a complete blood count, blood type and testing for sexually transmitted infections such as hepatitis B, syphilis and HIV.

service provider: Ahmed was tested at Texas Health Mansfield Hospital, a tax-exempt hospital run by Texas Health Resources, a faith-based nonprofit health system, and AdventHealth, another religious nonprofit. Joint operation.

Total bill: The hospital was billed $9,520.02 for blood work and pathology services. The insurance company negotiated the fee down to $6,700.50 and then paid $4,310.38, leaving Ahmed with lab fees of $2,390.12.

What gives: Ahmed’s case reveals how high hospital labs often charge for tests. Even if the provider is in network, patients can spend thousands of dollars for routine blood tests that are much less expensive in other settings. Research shows that hospitals often charge much more than doctor’s offices or independent commercial labs for the same test.

Ahmed’s situation was particularly difficult because she lost her pregnancy.

“Coming to terms with it mentally, emotionally, physically—dealing with the consequences of the miscarriage—and then having to find the courage to start calling your insurance company, your billing department, your medical provider’s office to try to fight back “You feel Wrong bill sent? There’s just too many,” she said.

In Texas, the same lab test costs at least six times more in a hospital than in a doctor’s office, according to research from the Healthcare Cost Institute, a nonprofit organization that examines medical spending.

Depending on the test, the markup may be higher. HCCI data based on 2019 prices show that the median price for a complete blood count at an independent laboratory in Texas is $6.34 and the median price at a hospital is $58.22. The Texas Health Department charged Ahmed $206.69 for the test alone.

“It’s convenient to have lab tests done in the same building, but many patients don’t take into account how highly rated those lab tests are,” said Jessica Chang, a senior researcher at HCCI. Chang said she doubts Many hospitals add overhead costs to their insurance premiums.

Anthem also billed Ahmed for at least four tests that most insurance plans consider preventive care, so under the Affordable Care Act’s requirement to cover preventive care, including prenatal care, coverage is free to patients . Her EOB, or “Explanation of Benefits” notice, shows that she was tested for Rh factor (which detects proteins on the surface of red blood cells), as well as for hepatitis B, hepatitis C and syphilis at her own expense.

When asked to review Ahmed’s tests, Anthem spokesperson Emily Snooks wrote in an email to KFF Health News that the claims “are intended as diagnostic and not preventive Submitted and paid based on benefits in the member’s health plan.”

Sabrina Collette, co-director of the Center on Health Insurance Reform at Georgetown University, said there “absolutely should not be” an out-of-pocket cost for these tests.

The Centers for Disease Control and Prevention recommends screening pregnant patients for several infectious diseases that pose significant risks during pregnancy. Ina Park, a professor of family and community medicine at the University of California, San Francisco and an expert on sexually transmitted infections, said that from a clinical perspective, the test Ahmed received did not raise red flags. “It does cost more than what the lab charges based on the actual cost of the test,” Parker said. “The price is really too expensive.”

For example, Ahmed paid $71.86 in coinsurance for a hepatitis B test, while the hospital charged $418.55. The hospital syphilis screening cost $295.52; her out-of-pocket cost was $50.74.

“You just want to know, is the insurance company actually negotiating aggressively with that provider to keep the reimbursement within a reasonable range?” Collette said.

resolution: Ahmed refused to pay the bill, and Texas Health Department referred the debt to a collection agency. As she tried to get answers about the charges, she said she went back and forth between the doctor’s office and the hospital billing department. Ahmed filed a complaint with the Texas Attorney General’s Office, which forwarded it to the Texas Health and Human Services Commission. She never heard back.

According to Ahmed, a hospital representative said her blood test may have been miscoded and agreed that the charge was “really unusually high,” but she was told the hospital could not change that. The hospital has not commented on the reasons behind the high charges. In a March 7 email, an AdventHealth employee told Ahmed that the doctor’s office “has no control” over the hospital’s billing.

Ahmed appealed to Anthem, but his appeal was denied. The insurance company said the claim was processed correctly under her benefits, which covered 80 percent of the cost of in-network lab services the insurance company agreed to pay after she met her deductible. Ahmed’s deductible is $1,400, and out-of-pocket expenses for in-network providers are capped at $4,600.

“We rely on health care providers to submit accurate billing information regarding the medical services needed and provided,” Snooks said. When asked about Texas Health Labs’ reimbursement, she added, “ Claims are reimbursed under the laboratory’s contract with the health plan.”

After a KFF Health News reporter contacted the Texas Department of Health on Oct. 9, the hospital called Ahmed on Oct. 10 and said it would zero out the bill and remove the charge from collections. Ahmed breathed a sigh of relief, “It was like a huge burden had just been lifted off my shoulders.”

“We’ve been fighting this problem for 10 months and it’s finally gone,” she said.

Texas Health Resources and AdventHealth declined to answer detailed questions about Ahmed’s allegations and the tests she was ordered to undergo.

“We are sorry that Ms. Ahmed did not provide us with clarification about her care. Our top priority is providing safe, effective and medically appropriate care to our patients,” hospital spokesperson Laura Shea ) said in an emailed statement.

Key points: Ahmed’s questions illustrate the pitfalls of using hospital labs for routine testing.

For standard blood tests, “it’s hard to say there’s a quality difference” between independent labs and hospitals, thus requiring a higher price, Zhang said. This also applies to other services such as imaging. “There’s nothing special about the machines that hospitals use for CT or MRI scans. They’re the same machine.”

Overall, state and federal lawmakers are paying attention to the issue. Congress is considering legislation that would equalize payments for certain services regardless of whether they are provided in a hospital outpatient department or a doctor’s office, with the exception of laboratory services. Hospitals have tried to resist this policy, known as “site-neutral payment.”

For example, the Lower Costs, Increased Transparency Act would require physician-administered drugs under Medicare to have the same price regardless of whether they are provided in a doctor’s office or an off-campus hospital outpatient department. The bill also requires labs to disclose how much they charge Medicare for testing. Another bill, the Bipartisan Primary Care and Health Workforce Act, would prohibit hospitals from charging commercial health plans some facility fees that cover operating or administrative expenses.

Health care providers in Colorado, Connecticut, Ohio, New York and Texas are limited in their ability to charge privately insured patients facility fees for certain services, according to the National Conference of State Legislatures. Colorado, Connecticut, Maryland and New York require health care facilities to disclose facility fees to patients before care is provided; Florida has similar requirements for freestanding emergency departments.

Patients should keep copies of detailed bills and insurance policies. Although not the only evidence, these documents can help patients avoid paying out-of-pocket costs for recommended preventive screenings.

Currently, patients can proactively avoid such extreme costs: When your doctor says you need a blood test, ask that the request be sent to a commercial lab in your network, like Labcorp or Quest Diagnostics, and have the test completed there. If they are unable to do so electronically, please request a paper application.

“Don’t always go to the lab your doctor recommended for you,” Collette says.

KFF Health NewsFormerly known as Kaiser Health News (KHN), it is a national newsroom specializing in producing in-depth news on health issues and is one of the core operating projects of Kaiser Health News

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Emmarie Huetteman of KFF Health News edited the digital story and Taunya English of KFF Health News edited the audio story. NPR’s Will Stone edited the audio and digital story.