Carmen Aiken of Chicago made an appointment for an annual physical exam in July 2023, planning to get checked out and complete some blood work.

The appointment was at a family medicine practice run by University of Illinois Health. Aiken said the doctor recommended they undergo a Pap smear, which they hadn’t had in more than a year, and testing for sexually transmitted infections. Aiken, who works for a nonprofit and uses the pronoun they, said they were also encouraged to get the HPV vaccine.

They’d tested positive for HPV in 2019 and eventually cleared the virus but had not received the vaccine to prevent future infections.

“Sounds like a good idea,” Aiken, 37, recalled telling the doctor.

They also needed some lab work done, part of routine monitoring for one prescription. After being examined, Aiken said, they were directed to a different part of the office building to get blood drawn and receive the first dose of the vaccine before leaving.

Then the bill came.

The Medical Procedure

Services at Aiken’s appointment included a pelvic exam, a vaccination, and blood work, checking, in part, glucose levels and liver function.

An annual physical exam typically includes a variety of services, many of which insurers are required to cover under the Affordable Care Act, such as reviewing the patient’s health history, screening for high cholesterol, or performing a Pap smear, a procedure to check the cervix for signs of cancer.

Updating immunizations is also a common, covered service at checkups. The vaccine for HPV, or the human papillomavirus, provides protection against an infection that can cause several types of cancer. Federal health officials recommend being immunized for HPV at age 11 or 12, though the vaccine also can be administered later in life.

The Final Bill

$1,430.13: $1,223.22 for lab services and pathology, plus $206.91 for “professional services,” which included a charge for a 40-minute “High Mdm” outpatient visit — indicating a high level of “medical decision-making” — as well as charges for immunization administration and vaccines.

The Billing Problem: Diagnostic Blood Work With a Hospital Price Tag

Not all services that may be provided as part of an annual physical are paid for by insurance as preventive care.

A patient who needs blood work for a specific medical concern — as Aiken did, for medication monitoring — could be required to pay part of the bill. That’s the case even if the blood work is performed during a checkup alongside preventive services. Some health insurers pay for standard blood work as part of a preventive visit, but that’s not always the case.

Aiken had purchased a health insurance plan on the federal marketplace and said they were confident the visit would be covered at no cost to them.

When they got a bill for more than $1,400, Aiken thought, “How did this happen?” They said they called their insurer, BlueCross BlueShield of Illinois, then filed an appeal for the $1,223.22 amount they owed for lab services after their initial inquiry went nowhere. “Surely this is a misunderstanding.”

But their insurer sided with UI Health’s position that the blood work rendered during the appointment was not preventive. In a letter denying Aiken’s appeal, BlueCross BlueShield of Illinois decided that “the labs were billed correctly as diagnostic.”

Under the plan’s parameters, the insurer determined Aiken remained on the hook for 50% of the cost of outpatient labs performed in a hospital setting.

Dave Van de Walle, a spokesperson for BlueCross BlueShield of Illinois, would not discuss Aiken’s bill with KFF Health News.

Francesca Sacco, a spokesperson for UI Health, said in an emailed statement that Aiken scheduled the appointment for “medication monitoring and to obtain a vaccine.”

“Medication monitoring is not considered a wellness benefit under the Affordable Care Act,” she said.

Sacco also said Aiken’s labs were sent for processing to University of Illinois Hospital, more than a mile away from the family medicine practice.

That left Aiken owing more. Hospitals typically charge much more than physicians’ offices or independent commercial labs for the same tests.

The distinction between a preventive visit and a diagnostic one is important for billing purposes: It dictates who’s on the hook for the bill. A preventive visit generally comes at no cost to patients. But a visit for an ongoing medical issue is usually classified as diagnostic, leaving the patient subject to copays and deductibles — or even charged for two separate appointments.

Patients may not notice a difference in the exam room. Much of that nuance is determined by the medical provider and captured on the bill.

Confusion still persists 15 years after the ACA’s preventive services protections took effect, said Sabrina Corlette, a founder and co-director of the Center on Health Insurance Reforms at Georgetown University.

“This is an outrageous bill for what should have been routine care,” Corlette said. “People just don’t have this kind of money lying around.”

The Resolution

After the insurer denied their appeal, they “fell down a hole into despair about it for a while,” Aiken said.

“And then someone really wise was like, ‘You can pay it and then just stop thinking about it.’”

So that’s what Aiken did: “I put it on my credit card.”

UI Health’s Sacco said the hospital system is committed to working with insurers to resolve cost-sharing disputes.

“However, it is the insurance company’s sole discretion whether a service is fully covered or subject to cost sharing,” she said. “In this case, the insurer determined that cost sharing would be applicable to a specific portion of the services provided to the patient. Based on this determination, the patient was billed accordingly by UI Health.”

The experience left its mark on Aiken. Last year, they said, they walked out of an urgent-care visit after a doctor recommended a Pap smear — fearing they’d incur another large bill.

The Takeaway

Delaying or avoiding care can lead to worse outcomes, which is why lawmakers tried to ensure patients generally would pay nothing for preventive services, such as immunizations, under the ACA.

Annual checkups are a key element of preventive care. For instance, most adults who never received the HPV vaccine do not know they are still eligible, so it’s critical to inform them of their options, said Verda Hicks, a gynecologic oncologist based in Kansas City, Missouri.

The vaccine offers protection against nine types of HPV, she said. It also prevents HPV-related cancers in men, so the Centers for Disease Control and Prevention recommends boys receive the immunization, too.

“Get vaccinated,” Hicks said. “We just do not have the same tools for many other cancers.”

Keep in mind that your coverage may vary — some insurance companies won’t cover the cost of the vaccine for some older patients — and the same services may be subject to different cost-sharing rules depending on whether they are conducted for prevention versus diagnosis.

Also, prices can vary depending on where care is delivered and tests are performed. If you need a blood test, ask that your doctor send the requisition to a commercial, in-network lab. Patients may not realize that labs drawn at a clinic may be sent to a hospital for testing, exposing them to greater costs.

There has been a push in Congress to eliminate this price variation through “site-neutral” payment policies. Regardless of location, the price for routine care would be reimbursed at the same amount.

“Site-neutral reforms could potentially have significantly reduced Carmen’s expenses,” said Christine Monahan, an assistant research professor at Georgetown’s Center on Health Insurance Reforms.

Meanwhile, a case before the Supreme Court could upend the health system by eliminating the requirement that insurers cover preventive services like vaccines and annual screenings at no cost to patients. The high court heard oral arguments April 21.

If the justices side with the plaintiffs this term, Georgetown’s Corlette said, “then we all potentially lose access to free, high-value preventive care, and that would be a real shame.”

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

This article first appeared on KFF Health News and is republished here under a Creative Commons license.

Chantal Panozzo and her husband followed their primary care doctors’ orders last year after they both turned 45, now the recommended age to start screening for colorectal cancer. They scheduled their first routine colonoscopies a few months apart.

Panozzo said she was excited to get a colonoscopy, of all things, because it meant free care. The couple run a business out of their suburban home near Chicago and purchase coverage costing more than $1,400 each month for their family of four on the exchange, which was created by the Affordable Care Act.

By law, preventive services — including routine colonoscopies — are available at zero cost to patients. So Panozzo said she expected their screenings would be fully covered.

“This was our chance to get our free preventative care,” she said.

Their results came back normal, she said.

Then the bills came.

The Patients: Chantal Panozzo, who uses her maiden name professionally, now 46, and Brian Opyd, 45, are covered by Blue Cross and Blue Shield of Illinois.

Medical Services: Two routine colonoscopies (one for him, one for her), as recommended by the U.S. Preventive Services Task Force for patients beginning at age 45.

Service Provider: Illinois Gastroenterology Group in Hinsdale. The practice is part of the private equity-backed GI Alliance, which has more than 800 gastroenterologists working in 15 states, including Florida, Missouri, and Texas.

Total Bill: For each colonoscopy, the gastroenterology group charged $2,034 before any insurance discounts or reductions. After discounts, Blue Cross and Blue Shield of Illinois said it was responsible for paying $395.18 for Brian’s screening and $389.24 for Chantal’s.

But apart from the screening costs, the total included a $600 charge for each patient — though insurance documents did not identify what the charge was for. This left Chantal and Brian each with a $250 bill, the amount allowed by BCBS of Illinois, which was applied to their deductibles.

What Gives: Panozzo and her husband’s experience exposes a loophole in the law meant to guarantee zero-cost preventive services: Health care providers may bill how they choose as long as they abide by their contracts with insurance — including for whatever goods or services they choose to list, and in ways that could leave patients with unexpected bills for “free” care.

After their screenings, Panozzo said she and her husband each saw the same strange $600 charge from the Illinois Gastroenterology Group on their insurance explanation of benefits statements. Bills from the gastroenterology group explained these charges were for “surgical supplies.” Her insurer eventually told her the codes were for “surgical trays.”

At first, she was confused, Panozzo said: Why were they receiving any bills at all?

The Affordable Care Act requires preventive care services to be fully covered without any cost sharing imposed on patients — procedures such as colonoscopies, mammograms, and cervical cancer checks.

Policymakers included this hallmark protection because, for many patients, cost can deter them from seeking care. A KFF poll in 2022 found that roughly 4 in 10 adults skipped or postponed care they needed due to cost concerns.

Under the law, though, it is the insurer’s responsibility to make preventive care available at zero-cost to patients. Providers may exploit this loophole, said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

“The insurance company is supposed to pay the full claim, but there is no requirement on the provider to code the claim correctly,” Corlette said.

In this case, BCBS of Illinois covered the full cost of the screenings the couple received, according to its own documents. But those documents also showed that each patient was on the hook for a portion of their separate, $600 charges.

Panozzo thought a phone call with her insurer, BCBS of Illinois, would quickly fix the mistake. But she said she spent most of her time on hold and could not get an answer as to why the colonoscopy came with a separate charge for supplies. She said she learned in later communications with her insurer that the $600 was specifically for “surgical trays.”

BCBS of Illinois declined to comment despite receiving a waiver authorizing the insurer to discuss the case.

Panozzo said that she called the gastroenterology practice and was told by a billing representative that the extra charge was part of an arrangement the practice has with BCBS: She recalled being told that the practice was accustomed to keying in a billing code for “surgical trays” in lieu of a separate fee, which was described to Panozzo as a “use cost” for the doctor’s office.

“I was getting a different story from any person I talked to,” Panozzo said.

She said she was stuck in “no man’s land,” with each side telling her the other was responsible for removing the charge.

The Resolution: Panozzo went wide with her objections, contesting the total $500 they owed by filing appeals with her insurer; lodging a complaint with the Illinois Department of Insurance; and writing to her elected officials, warning that Illinois consumers were being “taken advantage of” and “ripped off.”

Ultimately, BCBS approved both appeals, saying neither Panozzo nor her husband was expected to pay the charges.

An administrative employee reached by phone at the Illinois Gastroenterology Group location where the couple was treated said they could not comment and directed KFF Health News to contact an executive with GI Alliance, the national group that manages the practice. Neither the executive nor media relations representatives responded to multiple requests for comment.

Panozzo said that, in the past, she would have paid the bill to avoid wasting time haggling with the doctor, insurer, or both. But getting hit with the same bill twice? That was too much for her to accept, she said.

MORE FROM BILL OF THE MONTH

• When a Quick Telehealth Visit Yields Multiple Surprises Beyond a Big Bill
• Out for Blood? For Routine Lab Work, the Hospital Billed Her $2,400
• When That Supposedly Free Annual Physical Generates a Bill

“If change is ever going to happen, I need to stop accepting some of these bills that I knew were potentially incorrect,” Panozzo said.

The Takeaway: Medical providers have broad leeway to determine how they bill for care, including by deciding how to identify what goods or services are provided. This means patients may get stuck with charges for unfamiliar or downright bizarre things.

And because the law doesn’t address how providers bill patients for preventive services, odd charges can crop up even for care that should be fully covered.

Research also shows private equity ownership, which has been increasing in specialties like gastroenterology, can lead to higher costs for patients, as well as lower quality care.

For patients, “under federal law, there is no recourse,” Corlette said. State regulatory bodies may go after these providers for billing patients for covered services, but that can be a mixed bag, Corlette said.

Insurers should crack down on this kind of practice with the providers participating in their networks, Corlette said. Otherwise, patients are stuck in the middle, left to contest what should be “free” care — and at the mercy of the insurance appeals process.

Health plans may not catch billing oddities — after all, for a major insurer, a charge of $600 may not be worth investigating. That leaves patients ultimately responsible for keeping track of what they’re being asked to pay — and speaking up if something seems suspicious.

Panozzo said the experience left her feeling defeated, exhausted, and distrustful of America’s health care system.

Having lived abroad with her family for almost 10 years, she said, “I could function in a health care system in German better than I could here in English.”

KFF Health News senior producer Zach Dyer reported the audio story.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Subscribe to KFF Health News' free Morning Briefing.

This article first appeared on KFF Health News and is republished here under a Creative Commons license.

In the summer of 2023, Eloise Reynolds paid the bill for her husband’s final stay in the hospital.

In February 2022, doctors said that Kent, her husband of 33 years, was too weak for the routine chemotherapy that had kept his colon cancer at bay since 2018. He was admitted to Barnes-Jewish Hospital in St. Louis, not far from their home in Olivette, Missouri.

Doctors discovered a partial blockage of his bowel, Reynolds said, but she remained hopeful that his treatment would soon resume.

“I remember calling our kids and saying, ‘OK, this is all really good news. We just need to get him kind of bolstered back up and feeling well,’” she said.

But years of chemotherapy had taken a toll on his body, and he told his wife that he couldn’t go on any longer.

Kent was discharged and began hospice care at home. He died the next month at age 62.

When Reynolds received the bill for the hospital stay, she paid the $823.15 it said her husband owed. She scribbled “paid” on the bill, memorializing the date, June 30, 2022 — the financial endpoint, she thought, of Kent’s years of treatment.

Then the bill came (again).

The Patient: Kent Reynolds, deceased, had been covered by Blue Cross and Blue Shield of Illinois through his Illinois-based employer.

Medical Service: A 14-day hospital stay related to complications from colon cancer, including a partially blocked bowel.

Service Provider: BJC HealthCare, a tax-exempt health system that operates 14 hospitals, mostly in the St. Louis area, including Barnes-Jewish Hospital.

Total Bill: The hospital charged $110,666.46 for the stay before any payments or adjustments. The insurer negotiated that price down to $60,348.77, and Reynolds paid the $823.15 the hospital said the patient owed. Then, a year after her husband’s death, she received a new version of the bill from the hospital, charging her an additional $1,093.16.

What Gives: Reynolds encountered a perplexing reality in medical billing: Providers can — and do — come after patients to collect more money for services months or years after a bill has been paid.

The new bill said Kent Reynolds had been enrolled in a payment plan and that the first “monthly installment” on the nearly $1,100 balance was soon due.

She said she called both the hospital and Blue Cross and Blue Shield of Illinois in search of answers but didn’t get an explanation that made sense to her.

According to Reynolds, a BJC HealthCare representative told her that the insurer had paid more than it owed, meaning the health system had to reimburse the insurer and charge the patient more.

Reynolds said she grabbed a yardstick to use as a straight edge and went line by line, comparing both bills, to see what had changed, a task that evoked painful memories of her husband’s last days. The amount for each individual charge — medications, lab tests, supplies, and more — was the same on both bills. The total had not changed.

Only three aspects of the bill had changed: the adjustments; the amount paid by the insurance company; and what the patient owed.

Adjustments, or discounts, are amounts that may be subtracted from a medical bill, typically under the provider’s pre-negotiated contract with an insurer. Insurers and providers agree to lower, in-network rates for services provided to patients covered by the insurer.

Reynolds also received an EOB, or “explanation of benefits,” notice showing the insurer reviewed the bill again in February, a year after the hospital stay. The document said the hospital’s charges for her husband’s private room — amounting to nearly $77,000 — were more than his health plan’s negotiated room rates, which did not cover the full cost.

The EOB noted that the patient could still owe the hospital $50,216.31 for the room charges — a startling amount — although Reynolds ultimately received no bill indicating she owed that much.

Reynolds said she spent hours trying to understand the items on the hospital and insurance paperwork, since they used medical abbreviations and were grouped differently on the documents.

“It shouldn’t be this hard for a widow to figure out what the medical bills were,” said Erin Duffy, a research scientist at the University of Southern California’s Schaeffer Center for Health Policy and Economics.

Blue Cross and Blue Shield of Illinois declined to comment despite receiving a signed release from Reynolds waiving federal privacy protections.

The Resolution: Unclear about what had changed and how much she owed, Reynolds held off on paying the second bill. After KFF Health News contacted BJC HealthCare, Laura High, a media relations manager for the system, said the charges were the result of a “clerical error.” Reynolds no longer has a balance, High said in an email in May.

“I was shocked by it,” Reynolds said. “I’m convinced most of the people I know would have paid this.”

High did not answer questions about the cause of the billing error or how often such errors occur.

However, Duffy provided a different explanation for the charges. “This doesn’t seem like an error,” she said. “It seems consistent with their insurance plan design.”

She said it appeared the additional $1,100 charge — assessed a year later — represented Kent’s coinsurance share of the private room charges, which she found as a recurring line item on each page of the bill under the heading “Oncology/PVT.”

While his coinsurance responsibility could have amounted to 10% of what the insurer paid in room charges — potentially a huge amount — Kent had met his out-of-pocket payment maximum for the year, so the charges did not reach the full 10% of the room costs, Reynolds said.

The Takeaway: In the United States, medical bills and insurance statements create a burdensome puzzle for patients to sort through to determine what is actually owed. The first rule of thumb is: “Don’t pay the bill before you’ve gotten the EOB,” which is the insurer’s accounting of what you owe and what the insurer will pay, said Kaye Pestaina, co-director of KFF’s Program on Patient and Consumer Protections.

In addition, ask for an itemized breakdown of charges and compare it against the EOB.

Medical billing experts said standardizing terms and other details on medical bills and EOBs would help patients enormously in this undertaking.

A few states have taken steps toward giving patients more information about health care charges, including by simplifying medical bills. In 2019, New York state lawmakers proposed requiring hospitals to provide patients with bills in plain language, including an itemized list of services labeled as paid by the insurer or owed by the patient. The proposal, which did not advance, required hospitals to send patients a single bill within seven days of leaving the hospital.

Reynolds’ experience highlights the lack of laws and standards around how long providers have to bill — and review bills — for medical services. Insurers may dictate in their contracts how long providers have to submit claims; the Medicare program has a 12-month limit to file claims, for instance. However, Dave Dillon, a spokesperson for the Missouri Hospital Association, said no laws restrict how long providers have to send a bill to patients.

Creditors may seek payment from a deceased person’s estate to collect whatever they can, said Berneta Haynes, a senior attorney at the National Consumer Law Center. In Missouri, a living spouse can be held responsible for a deceased spouse’s medical bills in certain instances, said Terry Lawson, a managing attorney for Legal Services of Eastern Missouri.

Experts said they did not pinpoint anything Reynolds could have done differently, noting that it is the system that needs to change.

“When can she move on from these hospital bills?” Duffy asked.

Stephanie O’Neill Patison reported the audio story.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Subscribe to KFF Health News' free Morning Briefing.

This article first appeared on KFF Health News and is republished here under a Creative Commons license.