Should my COVID test be covered?
November 17, 2020 4:57 PM   Subscribe

Help me understand why I received a surprise bill and what, if anything, I can do to fight it.

Last summer, in June, I was exposed to coronavirus at an internship I am required to complete for school. I was sent into quarantine and mandated to get a test. I live in New York and the internship was in Maryland. I get third party insurance but am also on Medicaid; I signed up for third party insurance through the New York State of Health Marketplace. I gave the urgent care facility my insurance info, got the test, and resumed my life as soon as it came back negative.

This morning I received an email stating that I had a balance on my account for an urgent care facility I haven't been to in five months. It was roughly $350. $50 went toward the test. Another $300 went toward a mandatory "office visit" in which I spoke to a provider through video chat, told them I needed a test, and they said "alright come to our drive through then". I made about 10,000 phone calls today to the NYS healthcare marketplace, my insurance company, the COVID hotline, the department of health in Maryland, and probably some other people I cannot remember. The gist of it is that everyone (barring the health department in Maryland, who told me they MAY be able to pay for it) is refsing to pay. I called Medicaid and they sent me to NYS of health. I called them and they told me that it should be covered but sent me to the COVID hotline, who told me it's not their problem and were unfamiliar with the law. I called my insurance company, who told me they needed to "look into this" and they would get back to me.

Meanwhile, I did some research on the CARES act. This is what I found (page 7):

Are plans and issuers required to provide coverage for items and services that are furnished by providers that have not agreed to accept a negotiated rate as payment in full (i.e., out-of-network providers)?

Yes. Section 3202(a) of the CARES Act provides that a plan or issuer providing coverage of items and services described in section 6001(a) of the FFCRA shall reimburse the provider of the diagnostic testing as follows:

1. If the plan or issuer has a negotiated rate with such provider in effect before the public health emergency declared under section 319 of the PHS Act, such negotiated rate shall apply throughout the period of such declaration.

2. If the plan or issuer does not have a negotiated rate with such provider, the plan or issuer shall reimburse the provider in an amount that equals the cash price for such service as listed by the provider on a public internet website, or the plan or issuer may negotiate a rate with the provider for less than such cash price.

Section 3202(b) of the CARES Act also requires providers of diagnostic tests for COVID-19 to make public the cash price of a COVID-19 diagnostic test on the provider’s public internet website. Section 3202(b) of the CARES Act also grants the Secretary of HHS authority to impose civil monetary penalties on any provider that does not comply with this requirement and has not completed a corrective action plan, in an amount not to exceed $300 per day that the
violation is ongoing.

Since my insurance is in New York, I was technically out of network when receiving the test, and my insurace does not provide out-of-network coverage. However, if I am reading this provision correctly, the insurance still has to pay the cash price listed on the provider's network, even IF the service is not occuring in-network. The urgent care facility doesn't list a price on their website, but anyway.

I read what I just pasted above to the woman at the insurance company on the phone, who then spent a solid 15 minutes yelling at me, saying that this is out of network (I know; that's my point) so it's not covered and they don't even have a negotiated price with this provider (again, that's my point you fucking assholes--insurers who don't have a negotiated rate are still required to pay for the test, if I am reading the provision correctly). Point is, they are flat refusing to pay it and I ended up filing an appeal.

I know the US health insurance system is a clusterfuck of terrible things, so help me understand. According to section 3202 it SHOULD be covered, but does it get fucky because this is a medisource plan, and I get medicaid through NYS? Have I run into some bizarre loophole here? Or is my insurance company bullshitting me?

Either way, how do I even begin fighting this? If it IS a violation of the CARES act, how do I proceed in making sure that everyone here is held accountable under the law? And if this IS a loophole, what are my options in getting this bill covered? I'm stressed and tired and don't have time to fight this, but wow $354 is a lot of money for this grad student.

Thanks in advance.
posted by Amy93 to Law & Government (23 answers total) 5 users marked this as a favorite
You are covered by Medicaid in New York, which presumably means you would be eligible for Medicaid in Maryland, too. I would send the urgent care facility a copy of your primary and secondary insurance, clearly stating you’re a Medicaid patient, and don’t pay the balance. What are they gonna do, sue you? You don’t live in Maryland. Send you to collections? You are a Medicaid patient, you have certified by the government as not having money, they’d be crazy to try it. There are still a few people to check in with, like the Attorney General of MD (see questions 15 & 16). Whatever you do, dig your heels in and don’t pay. $350 is not a lot of money to this place.
posted by ThePinkSuperhero at 5:13 PM on November 17, 2020 [1 favorite]

Not sure who your out-of network provider was, but if they received any funds from the CARES act, they can't balance-bill you for the out-of-network cost. Your insurance should hopefully be able to determine this for you, but if you want peace of mind, you can check the list of providers who received funds from the Provider Relief Fund here.

If a patient has insurance and seeks COVID-19 treatment from an out-of-network provider that has received General or Targeted Distributions from the Provider Relief Fund, the provider has agreed not to seek to collect out-of-pocket payments greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider.

posted by longdaysjourney at 5:16 PM on November 17, 2020 [1 favorite]

There are some bureaucracies that may help.
I would start by contacting your private insurance company and asking if they can help straighten out the provider. If that doesn't work, you can try the magic words "I'd like to file a grievance". You can also attempt to contact the state insurance commissioner, or maybe health commissioner? There are lots of procedural ways to get an insurance company to pay attention. I don't know the provider side as well, but finding out who regulates them is one way to go
posted by lorimt at 5:53 PM on November 17, 2020 [1 favorite]

Not that you have a ton of time or energy to deal with this, but if you still have questions after this ask, the Arm and a Leg podcast has spent a bunch of episodes lately talking about covid and financial self-defense, how to contest medical bills, covid test billing shenanigans, etc. It also links to resources like how to push back about a medical bill. And I definitely second longdaysjourney's suggestion on looking up if your provider took CARES funding. You are doing a great job of handling this and self-advocating. But it sucks and it's unfair.

But yeah this internet rando's opinion is do not get bullied into paying this yet. Good luck.
posted by jameaterblues at 6:01 PM on November 17, 2020 [2 favorites]

Response by poster: Hey, I super appreciate the answers so far. Real quick though, I'd like to highlight a specific part of my question: is anyone able to definitively say whether this is a violation of the CARES act? Or, who should I contact to see if they are in violation, if no one knows?

I would absolutely love to file a grievance if they are breaking the law. If not, to be honest, I don't want to waste my time. In that case, I'd much rather try to get the department of health in Maryland to cover it, or fight urgent care directly, since both of those seem like vaguely viable options.

Thanks a bunch either way.
posted by Amy93 at 6:17 PM on November 17, 2020

The Times had a recent article about surprise Covid costs. It sounds like you were charged a facility fee in addition to the covered test.
posted by icaicaer at 6:58 PM on November 17, 2020 [1 favorite]

Seconding "calling your third-party provider".

I had a similar surprise "you're not paying for that test?" moment myself - I got a Covid test as part of a round of pre-surgical screening tests before knee surgery in early October. Then last week I got a fat letter from my insurance company saying that they were going to reject the claim for that test.

All it took was one call to my insurance company to say "huh?" and explain the situation for them to realize that the provider had simply used the wrong code - they'd used the code for "this test was because the patient was exposed" instead of the code for "this patient was getting a crapton of tests before we gave her surgery". They said they would sort it out with the provider and ask them to resubmit with the right code, and they'd take care of that.

The insurance companies often have people who are there to help navigate this stuff.
posted by EmpressCallipygos at 7:25 PM on November 17, 2020

I'm a fellow grad student but not at your institution (and my university pays for my health insurance). With full recognition that your situation is different/less good than mine, I'll note that I've gotten decent mileage (and no small amount of emotional sustenance) out of finding the university administrator whose domain most closely overlaps with my problems, and cc'ing them on any and all issues, insurance included. In my situation it's low effort for infrequent high reward, but YMMV.
posted by deludingmyself at 7:55 PM on November 17, 2020

You are covered by Medicaid in New York, which presumably means you would be eligible for Medicaid in Maryland, too.

Medicaid, unlike Medicare, does not cross state lines. Your NYS Medicaid status is irrelevant here. The details of your third party plan are. If they truly don't provide any out-of-network coverage including urgent /emergent care (this is unusual), then you were effectively uninsured while in MD.

It's worth looking at your third party plan documents to see if what their rules are regarding out of network coverage. Most have a proviso like they won't cover PCP/specialist visits but they will cover 50% of emergent/urgent care, or whatever. Longdaysjourney's link is useful, as is EmpressCallipygos' suggestion about billing codes. There are COVID specific codes and if the urgent care doc typed one digit wrong or clicked the wrong button, the computer thinks it was an office visit instead of a covid screening visit.
posted by basalganglia at 7:55 PM on November 17, 2020 [4 favorites]

Also, this is absolutely worth addressing, and do not ignore because they can and will send you to collections, and that, unlike Medicaid, can indeed cross state lines and screw up your credit.
posted by basalganglia at 7:57 PM on November 17, 2020 [3 favorites]

Seconding icaicaer.

The New York Times doesn't just have a whole article on this, medical journalist Sarah Kliff has been doing an entire series. Scroll down and press "more," "more" and "more" to see the series in its entirety, dating back to April, which is to say pretty much the start of the plague. In August, in fact, Kliff published an open request for people to send her information on their covid medical bills. Although she may have all she needs by now, she makes it plain that she's always interested in medical billing practices, so you might just want to write in regardless.

From the article icaicaer cites and to answer your question specifically: In my read of this section of the Times article, the test and the office visit both should have been free, regardless of your permanent residency. I suspect that means Medicaid New York should cover any applicable out-of-network costs but, frankly, the easiest thing to do would be to contact your congressional rep, tell them you're a constituent and explain the problem. It's amazing what a single phone call from a rep will do. (If they don't help you, move on to your senator's office, but I doubt you'll need to go that far.) Political offices will be easier to deal with than Medicaid, the Maryland doctor's office and so on, and they all have friendly staff who function quite a bit like social workers in cases like this. Plus they will be familiar with the law anyway, if only because they voted on it.
To challenge a surprise bill, know your rights under federal law
New federal laws regulate how health providers and insurers can bill patients for coronavirus tests. Understanding how they work can help you push back on charges that may not be allowed.

The new laws state that health insurers must cover coronavirus tests without any cost to the patients. This means that standard deductibles and co-payments you’d face for other services do not apply.

Those laws also require insurers to cover any other services that are necessary to get the coronavirus test, but doesn’t define what makes the cut. Most experts agree that a doctor visit fee is a pretty clear example of a service that ought to qualify, and that patients facing those types of bills ought to appeal to their insurer for coverage. Other services, like a flu test or even an X-ray conducted alongside a coronavirus test, present a murkier situation. If you’re facing fees like those, you might want to enlist your doctor to tell the insurer why the additional care was needed.

One last thing to know about the federal laws is that they require insurers to fully cover out-of-network coronavirus tests. This can be especially important for patients who go to an in-network doctor but unknowingly have their sample sent to an out-of-network laboratory, a situation I’ve seen many times. Your health plan’s typical rules for out-of-network care should not apply to the coronavirus test. They can, however, be applied to other parts of the test experience (the doctor visit fee, for example), so it is safer to stick with in-network providers whenever possible.

posted by Violet Blue at 10:15 PM on November 17, 2020

Response by poster: That’s super helpful, violet blue. Can you just also post the link where you got the stuff in the smaller text?

posted by Amy93 at 6:16 AM on November 18, 2020

The quote Violet Blue posted is from their "article" link. (NYT link)

Here's a non-paywalled archive of the article.
posted by belladonna at 7:58 AM on November 18, 2020

Response by poster: Some updates:

I tried calling the attorney general in NYS, who told me they don't regulate Medicaid so they cannot help me.

I left a message for the NYS insurance commisioner's office.

I called Medicaid AGAIN and the man I spoke to was once again unfamiliar with the law and told me to try to contact the out of state medicaid office. I tried them and I got caught in a phone tree and no one answered. I ended up calling my local Medicaid office, who once again told me they don't know anything about this and had me call our local department of health.

I tried them and they told me this is not their job and they know nothing about this and referred me back to Medicaid.

At this point I am at an utter loss. I think it's a violation. I know my rights. But nobody I call will help me and I don't know who to call next.
posted by Amy93 at 9:50 AM on November 18, 2020

I just tried looking for "ny state health insurance ombudsman," and found this - it's a list of numbers for various complaints and appeals having to do with health insurance in NY state. It looks like about three or four different options might apply to you. I think you certainly have grounds for a complaint about getting the runaround.
posted by EmpressCallipygos at 10:01 AM on November 18, 2020

Medicaid, unlike Medicare, does not cross state lines. Your NYS Medicaid status is irrelevant here

In my professional experience, I can say that is not correct. A patient being covered by Medicaid in another state will have an affect on how their account is managed.

I still strongly suggest you reach out to the Attorney General of MD, whose office is set up specifically to review these situations on your behalf.
posted by ThePinkSuperhero at 10:20 AM on November 18, 2020

Response by poster: I've already tried most numbers that apply to me on that list. I'm combing through it trying to see if there aer any applicable numbers I haven't called. The attorney general's office put me through to the healthcare branch of the consumer's assistance office, who told me that they don't regulate Medicaid. My local social services office told me they don't handle billing. The number for NY health OPTIONS is no longer in service.

I'm not trying to threadsit; I just want to provide clarification. There is no oversight here and it looks like the bill wasn't written to accommodate these situations, which is remarkably frustrating. As a last ditch effort I left a voicemail for my local congressman (thankfully a Democrat) to at least make them aware that the law isn't being enforced in our local community. I don't even know if they'll call me back, though. I also have an appeal with the insurance company on file.

Attorney general of MD isn't a bad idea, but if the attorney general of NY isn't regulating Medicaid, I'm not sure if they can help either.
posted by Amy93 at 10:22 AM on November 18, 2020

You would be asking the Attorney General of MD to review the charges from the urgent care facility, which is in MD - Medicaid status might not be relevant because, like the Attorney General website says, "In most cases you should not have to pay for COVID testing".
posted by ThePinkSuperhero at 10:29 AM on November 18, 2020 [1 favorite]

Could it possibly be a situation like this, where a shady doctor has sweet talked himself into a deal with organizations to provide COViD testing, testing for thing he shouldn't be testing for, then billing patients outrageous amounts for many things like the phone call to get results?

I'd be surprised if there wasn't an explosion in the numbers of these doom profiteers, especially after seeing how easy it seems, the lack of real consequences, and the look-the-other-way complicity of the municipalities involved.
posted by dozo at 10:45 AM on November 18, 2020

Response by poster: Another update: I apparently had my offices mixed up. The attorney general's office called me back. They assigned me an advocate and put the case on file so they can look into it further.
posted by Amy93 at 10:59 AM on November 18, 2020 [5 favorites]

posted by EmpressCallipygos at 12:02 PM on November 18, 2020

Here is a great episode of the podcast 'An Arm and a Leg' that discusses this issue. An Arm and a Leg
posted by LightMayo at 8:48 AM on November 19, 2020

Response by poster: If anyone ever reads this in the future, the attorney general's office confirmed that my interpretation of the bill was correct and I won my appeal with the insurance company.

The CARES act states, in no uncertain terms, that insurance companies are to cover an amount for a coronavirus test, even if it's out of network, equal to the cash price listed on the provider's website. It is written in plain English on the bill. In spite of this, I spoke to 10+ people through Independent health and medicaid who all stated they had never heard of this and it must not apply to them. All of them were wrong.

They will try to lie cheat and steal their way out of playing. They will also try to bully your way into paying so they don't have to. Stand your ground. The only instances where they don't necessarily need to pay under federal law are those where the test is not medically necessary. This was mandatory; SOMEONE needs to pay it. If not my insurance company it should have been covered by my "employer" or the local health department.

Hold them accountable and fight like hell if they try to get out of doing their jobs.
posted by Amy93 at 6:12 PM on December 7, 2020 [4 favorites]

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