By Donna Rosato
Millions of Americans pay for medical care they expect to cost nothing. Here's how to make sure that doesn't happen to you.
A few weeks after Jennifer Delillo's annual breast cancer screening last August, she was happy to get a letter from her doctor saying all looked normal. But the correspondence she received later from her insurer wasn't so heartening: a bill for $800.
Delillo, 37, assumed the screening was free because the Affordable Care Act (ACA) requires preventive care services such as mammograms and vaccinations to be covered at no cost, as long as the patient goes to an in-network doctor.
Delillo had never been charged before. "I'm trying to be proactive about my health," says Delillo, who lives in Orange County, N.Y., and gets health insurance through her employer.
In previous years, Delillo's OB-GYN prescribed a mammogram along with an ultrasound, common for women like her with dense breast tissue. This time, Delillo went to her primary care doctor, who wrote a prescription for the exact same protocol, a mammogram and ultrasound. But this time, her insurer considered it diagnostic, and Delillo was charged even though her doctor intended the screening as a preventive test.
Delillo thought the bill was a mistake. But when she called her insurer, Blue Cross Blue Shield of Michigan (where her employer is headquartered), she was told an ultrasound is not covered as part of a preventive care screening, and the fact that her doctor requested one indicated that there was concern about an underlying health problem, so the screenings were diagnostic.
That surprised Delillo, who says she never had anything but a clean bill of health. She contacted her primary care doctor, who said that Delillo would need to contact the billing office to get it straightened out. Despite multiple calls, Delillo never got a resolution from the billing department.
After Consumer Reports contacted Blue Cross about the claim denial for this report, the insurer requested Delillo's medical records from her physician. A review by a doctor on the insurer's staff found no history of breast cancer issues. Blue Cross told Delillo it would fully cover the mammogram but not the ultrasound, reducing the bill to $400. The insurer wouldn't comment when asked by CR why the previous screenings with ultrasounds were free.
"I pay a lot for my health insurance," Delillo says. "This is not a bill I think I should pay."
When Free Preventive Care Isn't Free
Delillo got caught in a murky zone surrounding the interpretation of the ACA mandate about preventive care services-a problem that trips up millions of Americans who think they're receiving free healthcare services but instead get stuck with sizeable bills.
Sometimes it's a simple clerical billing error. But what's really driving the problem is that what qualifies for free preventive care isn't well-defined, and insurers and healthcare providers have different ideas on the standards.
Insurers deny claims for 1 in 10 preventive care screenings and medical tests, affecting 7.7 million Americans, according to a recent report by the Doctor-Patient Rights Project, an advocacy group that represents healthcare professionals and patient groups. About 40 percent of patients appeal these denials, but only half are successful, according to the DPRP report.
A separate nationally representative survey by Consumer Reports last year found that almost one-third of Americans with insurance received a surprise medical bill, many for $500 or more. And of those, 12 percent said the bills were for services that should have been free.
When the issue is a billing code error by the healthcare provider-say, the procedure is tagged as diagnostic when it should be preventive-it can be time-consuming to untangle, though consumers might clear it up with a few phone calls to their doctor and insurer.
The more daunting problem is that "there is a lot of gray area when it comes to what is preventive and what is not," says Karen Vogel, a medical billing advocate and consultant who helps people resolve health insurance billing disputes.
It happens even though the ACA guidelines are based on recommendations by the U.S. Preventive Services Task Force, an independent group of medical experts. But the guidelines can change as medical research evolves about which services are reliable predictors of health problems. Research also might suggest changing how frequently various tests are needed and for which patients. Also, some insurers go beyond the recommended guidelines while others stick to the basics. And the criteria for what qualifies you for free preventive care can be very specific, depending on your gender, age, health history, and even where you live, because some states have passed laws to better define it.
Challenging a Denial Is Challenging
The DPRP says what's more problematic is when insurers override doctor treatment decisions and question the medical necessity of a procedure, such as using an ultrasound in conjunction with a mammogram, as Delillo discovered. In about a third of cases, insurers deny claims for procedures or screenings because they deem them "not medically necessary," according to the DPRP report.
America's Health Insurance Plans, an industry association for private health insurance companies, disputes the DPRP's charge that insurers are creating barriers for people who want to take advantage of free preventive care.
"Health insurance providers want every single person to get their preventive care," Cathryn Donaldson, director of communications at AHIP, said in an email to Consumer Reports. "It helps ensure they stay healthy, and if there's a problem, it helps ensure they get care and return back to health quickly."
Donaldson says when a treatment is deemed unnecessary, it is based on medical and scientific evidence and is meant to protect patients from "excessive testing and treatment that is unnecessary and can cause harm." Consumers and doctors who don't agree with a claim denial can appeal and are entitled to an independent medical review, Donaldson says.
But that puts the burden on patients or their doctors to prove the treatment was necessary, says Stacey Worthy, legal counsel to Aimed Alliance, a nonprofit organization focused on improving access to quality healthcare and a member of the DPRP.
It's a time-consuming process. If you file a formal appeal, you need to get your medical records, bills, paperwork explaining the denial, your insurer's guidelines, and letters of support for the treatment from your doctor or research studies showing the treatment is effective in cases like yours.
Even if the charge is eventually reversed in your favor, a healthcare provider can send the bill to collections while it's being disputed, potentially hurting the patient's credit, Worthy says.
Beyond the financial impact, there could be a health cost, too. The point of making preventive care free is to encourage people to get screenings and catch health conditions before they become serious, says Theresa Rohr-Kirchgraber, M.D., a primary care physician and former head of the American Medical Women's Association. That can reduce healthcare spending nationwide and lower the cost of insurance for everyone.
"Getting hit with unexpected bills could potentially deter people from seeking care that could prevent costlier treatment and worse health outcomes in the long run," Rohr-Kirchgraber says.
Delillo, for one, says she's not sure she'll continue to get regular breast cancer screenings. "I don't want to be charged or have to argue about the bill every time."
The Financial Impact
Free preventive services cover a wide range of care, including colonoscopies, lung cancer screening, blood pressure monitoring, vaccinations, annual "well woman" physicals, cholesterol tests, nutrition counseling, and diabetes management. The law applies to most insurance, whether you buy it yourself, get it through your employer, or use Medicare or Medicaid.
The financial impact of not getting a service covered varies widely, depending on the procedure and your insurance plan. But after copays, coinsurance, and the amount you must pay before you meet your deductible, you could owe hundreds or thousands of dollars, even if insurance covers part of the cost.
One in 5 working-age Americans with health insurance report having problems paying medical bills and say it causes serious financial issues, according to a survey by the Kaiser Family Foundation. Among people who reported struggling to pay medical bills, 75 percent said they cut back spending on food, clothes, and other basic household items; 63 percent said they used up most or all of their savings; and 42 percent worked more hours or took on an extra job to pay the bill.
'I Figured It Was Just Routine'
A $4,000 bill for a colonoscopy last summer gave Michele Martini a financial shock. During a routine visit to her primary care doctor, Martini, 57, mentioned she had some bloating and diarrhea. He suggested that she see a gastroenterologist, who in turn recommended a colonoscopy.
Martini had never had a colonoscopy, though it is an ACA-mandated free screening for most people after age 50. "I figured it was just routine," says Martini, who lives in Houston and has health insurance through her employer. The procedure turned up no problems, and Martini said after changing her diet and using probiotics, her symptoms went away.
Martini and her husband were in the midst of buying a new home when she got the bill. At the time, they were paying two mortgages because they closed on their new home before they sold their former one. "I didn't have $4,000 lying around," she says. "The doctor didn't find anything, and they want me to pay for something that should be free." Martini is still fighting the bill, which her doctor is threatening to send to collections.
Even a small bill can take a toll. Stacie Welsh had what she thought would be a no-cost colonoscopy to screen for colon cancer last year. Afterward, the doctor told her he did a biopsy on some tissue that he thought was problematic but turned out to be nothing. When she got the explanation of benefits from her insurer, she saw that the colonoscopy was marked as diagnostic, not preventive, and she owed $75.
Welsh, 58, has been unable to work since contracting a virus two years ago that attacked her nervous system and makes it difficult to walk. Though she is under 65, she is on Medicare because of her disability. "I have limited income, so a bill like this makes a difference," says Welsh, who lives in Collingswood, N.J.
What Is Preventive Care, Anyway?
Welsh's experience highlights another gray area: when a screening turns from "preventive" to "diagnostic" because the test detects something, even if the finding turns out to be erroneous.
That's what happened in 2014 to Jeff P., who asked that his full name not be used because he is still disputing the bill with his insurer and doctor.
A self-employed architect, Jeff was buying his own insurance at the time through the ACA health insurance exchanges. (He's now 66 and has Medicare.) During the colonoscopy, his doctor found a polyp and removed it to do a biopsy, which found it wasn't cancerous. Then Jeff got a bill for $700 for removal of the polyp. "Next time I have a colonoscopy, I'm going to tell the doctor if he finds something, don't remove it until I find out more about what I'll be charged," he says.
Other problems arise because the criteria of what counts as preventive care can be so specific. Some medical services are covered annually, such as well-woman visits. But others are periodic or depend on your age and health profile or apply only to women or children. Counter-intuitively, a lung cancer screening is considered preventive only for people ages 55 to 80 who have smoked a pack a day for 30 years. A cholesterol blood test is recommended every four to six years for men starting at age 35, but for women the recommendation is to start screening at age 45 or older.
A woman may be given the option of having a 3D mammogram or a 2D when getting a preventive breast cancer screening, but her insurer might cover only 2D, says Vogel, the medical billing consultant. She says even though there is no evidence that 3D screening is any better at detecting a problem than 2D, women are often encouraged to get the more expensive 3D screening. "It feels like an upsell," Vogel says.
Your own past health history can be a complicating factor, too. Someone who was previously prescribed a diagnostic test because something was suspected to be amiss could fall into the diagnostic category for future screenings even if no problem is ever found. Some insurers will cover a person who has breast cancer for free mammograms if she has been in remission for five years or longer. Others will not.
What to Do
All the confusion leaves consumers in the middle. Here's what to do to prevent getting charged for services that should be free and how to fight the bill if you do.
Know the law. Go to healthcare.gov to see the ACA guidelines on what is covered as preventive services. Stay on top of changes by checking the Kaiser Family Foundation's Preventive Services Tracker, which provides up-to-date information on services covered.
Talk to your insurer. Find out ahead of time what your insurance covers. Contact your insurer and ask for written documentation of what services are considered preventive. Ask whether your insurer can provide the specific preventive billing codes it accepts for the services you are planning to get.
Ask your doctor. To help prevent coding errors or misunderstandings, talk to your healthcare provider about how they plan to bill the services and provide the billing codes if your insurer can give them to you. Be sure to ask whether additional tests, which might not be considered preventive, will be done. For example, if a woman has an annual physical and her doctor also orders a blood test to check for iron deficiency, that lab work might not be covered free.
Check state laws. Several states have passed their owns laws to clarify what insurers should cover as free preventive care. Knowing state laws helped New York resident Mary Cook, 54, win a dispute when she had a mammogram that included an ultrasound, the same situation that triggered Jennifer Delillo's surprise bill. In 2016, New York passed a mammography law mandating no out-of-pocket expenses for breast cancer screenings, including those done with ultrasounds or MRIs. Cook, who buys her own health insurance through the ACA exchanges, was charged only a $35 copay. It took multiple phone calls and emails with her insurer to get it waived. But she says it was worth the time. "I pay $1,252 a month for a Platinum policy. It could happen on bigger bills. And if it's happening to me, it's happening to other people too," Cook says.
Call your state insurance department to find out the laws in your state. Disease-specific organizations often can guide you, too. The American Cancer Society, for example, has information on federal and state laws for colon cancer screening. And Dense Breast-Info, a nonprofit dedicated to educating consumers and medical professionals about dense breast issues and treatments, has a listing of insurance coverage laws for every state.
Appeal to your insurer. If you can't get your insurer to cover a bill, you have the right to appeal the decision. The Doctor-Patient Rights Project report found that when patients file a dispute, they won their appeal 50 percent of the time. For more information on how to file an appeal, use this free guide from the Patient Advocate Foundation, "A Patient's Guide to Navigating the Insurance Appeals Process," which includes sample appeal letters.
File a complaint. Lodging a complaint with your state insurance regulator could give you more bargaining power if you're disputing a bill with an insurer or a healthcare provider, says Adria Goldman Gross, owner of MedWise Insurance Advocacy, a consulting company that helps people with medical billing problems. "Don't pay the bill while you're fighting it," Goldman Gross says. "Once it's paid, it's hard to get the money back."
To find out where to file a complaint in your state, use Consumer Reports' Insurance Complaint tool or Aimed Alliance's state-by-state Coverage Rights guide.
MORE ON FIGHTING MEDICAL BILLS
- How to Protect Yourself From Surprise Medical Bills
- 6 Ways to Fix Mistakes on Your Medical Bills
- How to Get Help With Your Medical Bills
- What Medical Debt Does to Your Credit Score