The $25,865 Head Cold. It's A Christmas Medical Miracle!

I'm out of network? You're out of network! THIS WHOLE COURT IS OUT OF NETWORK!

National Public Radio brings us one hell of a fine story today about a ridiculous medical bill for a routine doctor's visit. In October, a nice lady in Brooklyn, Alexa Kasdan, was getting ready for a trip, but she had a cold that had lingered for over a week. She didn't want to go ahead with the vacation if she had strep throat or something awful, so she went to see her doctor, just in case. Her primary care doc, Roya Fathollahi, gave her a throat swab and took some blood, and sent her home with a prescription, and all was well. Kasdan felt better, went on her trip, and that's the end of our story because we figured you could use some nice news for a change where everything worked out fine, the end.

What, you're still reading? Oh, yeah, you probably read the headline. Although sometimes we wonder about some of you and you know who you are. 

Well fine then, what really happened was that she felt fine and had a nice vacay overseas, but then when she got home, Kasdan told NPR, there were "several messages on my phone, and I have an email from the billing department at Dr. Fathollahi's office." Turns out the lab that processed her tests was out of network for her insurance, and had billed $28,395.50. For freaking lab tests. But not to worry, her partner's insurer, Blue Cross and Blue Shield of Minnesota, was sending a check for something north of $25K, and the doctor's office had graciously agreed not to bill her for the balance.

So while this isn't exactly your usual "surprise medical billing" horror story, in that Ms. Kasdan isn't on the hook for thousands and thousands of dollars for services she thought would be covered, there's still the question of how the hell a blood test and throat culture ended up costing the price of a new Subaru Outback, including maybe the undercoating, which is a ripoff. Kasdan sent the bill and the story toBill of the Month , a project of NPR and Kaiser Health News that's aimed at explaining why the hell healthcare in this country costs so much.

For one thing, Dr. Fathollahi ordered a whole assload of tests on Kasdan's samples -- far more than you'd need to just rule out an infection or the flu.

Dr. Ranit Mishori, professor of family medicine at the Georgetown University School of Medicine, says such scrutiny was unnecessary.

"In my 20 years of being a doctor, I've never ordered any of these tests, let alone seen any of my colleagues, students and other physicians order anything like that in the outpatient setting," she says. "I have no idea why they were ordered."

The tests might conceivably make sense for a patient in the intensive care unit or with a difficult case of pneumonia, Mishori says.

Checking for flu is a good idea, but far cheaper tests are available.

Also too, the test was done by an out-of-network lab, which charged "20 times higher than average for other labs in the same ZIP code." If the very same tests had been done at an in-network lab -- which, yes, in New York City there definitely is one -- the total, even with all the bells and whistles, would have been roughly $653. That's a bit of a difference!

So why choose this lab? Surprise, surprise, Dr. Fathollahi appears to own an interest in the lab, "which has the same phone number and locations as [Kasdan's] doctor's office." The lab is called "Manhattan Gastroenterology," and the medical practice is "Manhattan Specialty Care." NPR couldn't verify 100 percent whether one company owns the other, because mandatory filings for the lab and the doctor's office allow a degree of opacity. And funny thing, nobody at either place, including Dr. Fathollahi, would talk to NPR.

Yeah, that sort of thing IS legal. And it's one of several reasons healthcare costs so much, even though Kasdan didn't have to pay extra, because insurers pass on those high costs in the form of higher premiums. Unfortunately, says Richelle Marting, a lawyer who specializes in medical billing (yes, of course that's a specialty, this is America!), the medical billing process is also increasingly automated, so "There's never a human set of eyes that look at the bill and decide whether or not it gets paid." After Kasdan went to the media and reporters started nosing around, however, her insurer "stopped payment on the check it issued and is now investigating," so that's interesting.

The piece also recommends that any time you get medical care for virtually anything, it's a good idea to ask whether labs or assistant surgeons or the best boy and key grip are in network. And to be an informed medical consumer in general, too:

"It is OK to ask your doctor, 'Why are you ordering these tests, and how are they going to help you come up with a treatment plan for me?' " says Georgetown's Mishori. "I think it's important for patients to be empowered and ask these questions, rather than be faced with unnecessary testing, unnecessary treatment and also, in this case, outrageous billing."

New York has a number of laws aimed at preventing surprise billing, although as we noted last week, the US Congress punted on a bill to address the problem, after members sympathetic to doctors' groups fucked the whole thing. (Thank you, Richard Neal! We are being sarcastic!) In New York, at least, patients must be told whether labs or providers are out of network; and if not, the patient can't be held responsible for those charges. Kasdan says she wasn't told that, and recall she isn't being billed.

This is also a problem that wouldn't be solved simply by switching to a single-payer system. A full Medicare for All system would eliminate worries about whether providers are in network, but any solution would also have to include stricter regulations to cut down on expensive unnecessary tests, or doctors sending business to their own practices' ancillary services like labs. Gosh, but if we cut out the profiteering we'd probably have no doctors, huh?

[ NPR ]

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