When Juliana Kessler, 15, broke an arm, a clinic required her mother, Laura Gottsman, to agree to pay for a sling if her insurer refused. Credit Peter DaSilva for The New York Times
Leo Boudreau of Massachusetts was thrilled to find a psychologist in his insurance network to treat his teenage daughter for emotional stress related to a medical condition. The therapist worked out of a local hospital.
But he was surprised when the bill for each visit contained two charges: the approximately $100 he expected to see for the therapist — and a similar fee for the room, which was not covered.
“How could it be that the doctor was in network and the hospital was in network, but I had to pay separately for the room?” Mr. Boudreau said.
As insurers ratchet down payments to physicians and hospitals, these providers are pushing back with a host of new charges: Ophthalmologists are increasingly levying separate “refraction fees” to assess vision acuity. Orthopedic clinics impose fees to put an arm in a cast or provide a splint, in addition to the usual bill for the office visit. On maternity wards, new mothers pay for a lactation consultant. An emergency room charges an “activation fee” in addition to its facility charges. Psychologists who have agreed to an insurer’s negotiated rate for neuropsychological testing bill patients an additional $2,000 for an “administration charge.”
A series of articles by the New York Times correspondent Elisabeth Rosenthal examines the price of medical care in the United States. In each installment, readers were invited to share their perspectives on managing costs and treatment.
In some cases, such as refraction, the services were never typically covered by health insurance but had generally been performed gratis as part of an exam. In others, the fees are novel constructs. In any case, as insurers and providers fight over revenue in an era of cost control, patients often find themselves caught in the middle, nickel-and-dimed.
Some of the charges come directly out of patients’ wallets at the time of treatment and catch patients off guard. And if they do not write a check for the refraction fee, for example, many doctors will not dispense a prescription for the glasses.
When Laura Gottsman took her 15-year-old daughter to the Palo Alto Medical Foundation in California last month with a broken arm, she had to sign a special form agreeing to pay for the sling if the insurer did not. A sling charge? Both of her daughters previously had broken arms set at the clinic, and she had not encountered such forms or charges.
“There really wasn’t an option to say, ‘No, I don’t want the sling,’ ” she said. She had not yet received the bill. Liz Madison, a spokeswoman for Sutter Health, which owns the clinic, said that a sling counted as a type of durable medical equipment and that patients typically paid for such items.
Cindy Weston of the American Medical Billing Association, an industry group, said it was up to physicians to decide what to include in their principal payment and what merited an extra charge. She said they now “may be forced to charge” for new services because the Affordable Care Act “has shifted so much responsibility for payment from insurers to patients” and patients do not pay as reliably as insurers.
Kyle Thompson-Westra’s policy covers preventive care, but he had to pay $300 for blood work done as part of a physical. Credit Taylor Glascock for The New York Times
These new fees are worrisome to health advocates. At a time when the country is trying to hold down health care costs, payments from patients shift spending to a place where they cannot be readily tallied. Also, such fees often undercut mandates under the Affordable Care Act that certain vital services for women’s health and preventive care be provided at no cost to patients: An intrauterine device is covered, but there is an insertion fee. An annual physical is covered, but not some of the blood work that a physician has ordered.
Knowing that his new policy under the Affordable Care Act covered preventive care, Kyle Thompson-Westra, 28, a business student in Chicago, selected a doctor in his network and went in January to get his first physical in years.
His insurer paid the doctor’s office about $600 of the $900 bill. He owed over $300 for blood work. There were several tests, such as thyroid function, that the doctor considered part of a routine physical, but that the insurer insisted were not.
The Affordable Care Act gives guidance on what kinds of exams must be covered at no cost as preventive services. But Clare Krusing, a spokeswoman for America’s Health Insurance Plans, an industry group, said, “If a provider chooses to do something beyond what’s covered, there may be charges.”
Medicare requires doctors to inform its patients in advance about any service they are dispensing that they believe the government insurer will not cover, and provide an accurate estimate of what the patient will have to pay. But there are no such protections in commercial insurance.
Even when insurance pays, the new fees undercut patients’ efforts to become better consumers of health care.
When Stephen Harman and his wife went to Mount Sinai Health System’s Roosevelt Hospital in New York for a scheduled induction of labor for their second child, they were instructed to report to a room next to labor and delivery on the 12th floor. There, the couple filled out some forms and answered a few questions.
When Mr. Harman got the bills, what he called “a brief march into that room” had translated into a $1,400 “E.R. fee,” which his insurer paid, although he was initially billed for an emergency room co-payment. Dorie Klissas, a spokeswoman for Mount Sinai Roosevelt, said, “We are committed to ensuring appropriate billing and will review this encounter with the patient.”
Likewise, after Linda Osburn drove her stepdaughter, Anna Hardenberg, 16, to an emergency room in Aitkin, Minn., after a bicycle crash, she was surprised to find on her bill a $2,457 fee for “noncritical activation” of the trauma team in addition to the hospital’s $240 facility fee.
Trauma teams are traditionally called in for ambulances transporting patients with devastating injuries, such as victims of major car wrecks and those with gunshot wounds. The girl had sat in the waiting room, answered nurses’ questions at registration and walked into the exam room before having her head scanned and being sent home.
The family’s charges under the terms of their insurance were about $1,000 of a bill of nearly $7,000, which included the trauma activation fee and an $84 charge for a soft cervical brace that was placed on her daughter when she entered the emergency room before she was scanned. Ms. Osburn added, “We didn’t even get to take that home.”