The lab technician who watched me all night via video feed told me that I had “wicked sleep apnea” and that it was “central sleep apnea” 鈥� a type that originates in the brain and fails to tell the muscles to inhale.

As a journalist 鈥� and one terrified by the diagnosis 鈥� I set out to do my own research. After a few weeks of sleuthing and interviewing experts, I reached two important conclusions.

First, I had moderate apnea, if that, and it could be treated without the elaborate machines, mouthpieces, or other devices that specialists who had consulted on my care were talking about.

Second, the American health care system has joined with commercial partners to define a medical condition 鈥� in this case, sleep apnea 鈥� in a way that allows both parties to generate revenue from a multitude of pricey diagnostic studies, equipment sales, and questionable treatments. I was on a conveyor belt.

It all began with a desire for answers: I had been feeling drowsy during the day, and my wife told me I snored. Both can mean obstructive sleep apnea. With obstructive sleep apnea, the mouth and throat relax when a person is unconscious, sometimes blocking or narrowing the airway. That interrupts breathing, as well as sleep. Without treatment, the resulting disruption in oxygen flow might increase the risk of developing certain cardiovascular diseases.

So I contacted a sleep-treatment center, and doctors gave me an at-home test ($365). Two weeks later, they told me I had “high-moderate” sleep apnea and needed to acquire a continuous positive airway pressure, or CPAP, machine, at a cost of about $600.

Though I had hoped to get the equipment and adjust the settings to see what worked best, my doctors said I had to come to the sleep lab for an overnight test ($1,900) to have them “titrate” the optimal CPAP air pressure.

“How do you treat central sleep apnea?” I worriedly asked the technician after that first overnight stay. She said something about an ASV (adaptive servo-ventilation) machine ($4,000). And one pricey lab sleepover wasn’t enough, she said. I needed to come back for another.

(Most procedures and devices mentioned in this article were covered or would have been covered by insurance 鈥� in my case, Medicare, plus a supplemental plan. Unnecessary care is a big reason Americans’ insurance costs 鈥� premiums, copays, and deductibles 鈥� tend to rise year after year.)

As a journalist who spent years covering the business of health care, I found there was more motivating my expensive testing cascade than concerns about my health.

The American Academy of Sleep Medicine, or AASM, a nonprofit based near Chicago, decides what is sleep apnea and how to treat it. Working with sleep societies around the world, it publishes the International Classification of Sleep Disorders, relied on by doctors everywhere to diagnose and categorize disease.

But behind that effort lie considerable conflicts of interest. Like so much of U.S. health care, sleep medicine turns out to be a thriving industry. AASM finances its operations in part with payments from CPAP machine manufacturers and other companies that stand to profit from expensive treatments and expansive definitions of apnea and other sleep disorders.

Zoll Itamar, which makes the I used, as well as for central sleep apnea, is a $60,000, “platinum” partner in AASM’s . So is , which is testing a drug to treat narcolepsy, characterized by intense daytime sleepiness.

Other sponsors include the ; another ; Healthcare, which makes CPAP machines and masks; and , maker of a heavily advertised surgical implant, costing tens of thousands of dollars, to treat apnea.

Corporate sponsors for , a convention AASM put on in Charlotte, North Carolina, with other professional societies, included many of those companies, plus and , two of the biggest CPAP machine makers.

In a statement, AASM spokesperson Jennifer Gibson said a conflict-of-interest policy and a non-interference pledge from industry funders protect the integrity of the academy’s work. Industry donations account for about $170,000 of AASM’s annual revenue of about $15 million, she said. Other revenue comes from educational materials and membership and accreditation fees.

Here’s what else I found. Almost everybody breathes irregularly sometime at night, especially during REM sleep, characterized by rapid eye movement and dreams. Blood oxygen levels also fluctuate slightly.

But recent European studies have shown that standards under the International Classification of Sleep Disorders would doom huge portions of the general population to a sleep apnea diagnosis 鈥� whether or not people had complaints of daytime tiredness or other sleep problems.

A showed that 50% of local men and 23% of the women 40 or older were positive for sleep apnea under such criteria.

Such rates of disease are “extraordinarily high,” “astronomical,” and “implausible,” Dr. Dirk Pevernagie, a scientist at Belgium’s Ghent University Hospital, in a comprehensive study in the Journal of Sleep Research.

“Right now, there is no real evidence for the criteria that have been put forward to diagnose obstructive sleep apnea and rate its severity,” he said in an interview.

Likewise, 19% of middle-aged subjects in a appeared to have moderate to severe “apnea” under one definition in the International Classification of Sleep Disorders even though many reported no drowsiness.

“Most of them were really surprised,” said Erna Sif Arnardóttir, who led the study and is running a to refine detection and treatment of apnea.

Nevertheless, the official extremely broad screening for sleep apnea, looking for patients who have what it defines as illness. Everybody 18 and older should be screened every year for apnea if they have diabetes, obesity, untreated high blood pressure, or heart disease 鈥� about sleep problems, the group says.

AASM “continually evaluates the definitions, criteria and recommendations used in the identification of sleep apnea and other sleep disorders,” Gibson said in the statement. Meanwhile, routine screening by primary care doctors “is a simple way” of gauging whether a high-risk patient may have obstructive sleep apnea, the statement said.

The U.S. Preventive Services Task Force, an authoritative body that reviews the effectiveness of preventive care, takes a conservative view, more like that of the European researchers, concluding there is to support widespread screening among patients with no symptoms.

Many insurers CPAP machines and other treatments prescribed for people at the outer edges of the AASM’s apnea definition. But AASM is .

After all my reporting, I concluded that my apnea is real, though moderate. My alarming reading in the overnight lab 鈥� diagnosed quickly as central sleep apnea 鈥� was a byproduct of the testing machinery itself. That’s a well-described phenomenon that occurs .

And when I looked closely at the results of my at-home diagnostic test, I had an epiphany: My overall score was 26 breathing interruptions and blood-oxygen level declines, on average, per hour 鈥� enough to put me in the “high-moderate” category for apnea. But when I looked at the data sorted according to sleeping positions, I saw that I scored much better when I slept on my side: only 10 interruptions in an hour.

So I did a little experiment: I bought a $25 pulse oximeter with a smartphone app that records oxygen dips and breathing interruptions. When I slept on my side, there were hardly any.

Now I sleep on my side. I snore less. I wake up refreshed. I’m not daytime drowsy.

None of my specialists mentioned turning on to my side 鈥� known in medical parlance as “” 鈥� though the intervention is recognized as effective by many researchers. Sleeping on one’s back contributes to snoring and blockages, especially as people age and the muscles in the throat become looser.

“Positional patients 鈥� can sleep in the lateral position and sleep quite well,” said Arie Oksenberg, a sleep researcher formerly at Loewenstein Hospital in Israel.

But it’s not easy to find this in , which instead go right to the money-making options like CPAP machines, surgery, central apnea, and mouth appliances.

Dealing with apnea by shifting slightly in bed gets little more than a couple of paragraphs in AASM’s and a little box on a .

A third or more of patients using them. It turns out people don’t like machines in their beds.

“Positional therapy is an effective treatment option for some patients,” said the AASM’s Gibson. But she said there are concerns about whether patients will sleep on their sides long term and whether trying to stay in one position might cause sleep interruptions itself.

It’s true that side-sleeping doesn’t help everybody. And it often takes practice. (Some people tape a tennis ball to their pajamas to keep them off their backs.) Even conservative sleep doctors say CPAP machines are the best solution for many patients.

But there is a largely overlooked alternative.

“Are we missing a simple treatment for most adult sleep apnea patients?” was the name of a that Oksenberg and a colleague wrote about positional therapy.

In my case, the answer was “yes.”

Jay Hancock is a former KHN senior correspondent.

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“Rapid Tests Are the Answer to Living With Covid-19” was the headline on an October he co-authored.

The Atlantic “America’s biggest antigen-test advocate.” In much of the world, rapid tests are “free for people and sold to governments for $3 ea[ch] to offer to their residents,” he tweeted last May.

On Oct. 22, he was one of a on a Zoom call to advise the Biden administration to urgently ramp up testing by purchasing and sending Americans free tests.

But three weeks after that call, on Nov. 12, Mina announced he was leaving academia to become an executive at eMed, a startup that sells some of the most expensive rapid tests.

In doing so, he joins the list of covid authorities who are both frequently quoted experts on national pandemic policy and working for companies profiting from that advice.

Other prominent voices on covid policy with industry ties include Scott Gottlieb, a former FDA commissioner under President Donald Trump who is now a director for Pfizer, maker of a leading covid vaccine; Jeffrey Klausner, a public health professor at the University of Southern California as well as a paid adviser to the ; and Deborah Birx, Trump’s top covid adviser who became chief medical and science adviser to ActivePure Technology, an air-purifier company.

The transitions drew criticism from some ethics authorities who cite concerns about transparency, credibility, and possible conflicts of interest.

“If Dr. Mina is acting in the capacity of a public health expert and he is financially connected to a company that could benefit from his public comments, he is in a financial conflict of interest,” said Sheldon Krimsky, a professor at Tufts University and the author of “Conflicts of Interest in Science.”

Mina said he is an eMed shareholder but declined to specify his holdings or say how much he is paid in his new position as the company’s chief science officer.

Mina, who spent time as a young man in Sri Lanka, where he was ordained as a Buddhist monk, argues he can do much more good at eMed, which certifies test results and plans to expand to testing for other diseases, than he could have at Harvard. He strives to clarify that he has shifted to being a businessman, he said.

“I’m frustrated with this narrative that industry is the dark side,” he said in an interview. “I don’t think it is. I think it’s where the action happens.”

Those who agree with that perspective note that the government has often stumbled in its pandemic response.

“If ever there were a time when it became clear that scientists collaborating with industry can achieve tremendous good, it was during this pandemic,” said Michael Cannon, director of health policy studies at the Cato Institute, which promotes free markets. “The private sector is responsible for creating nearly everything that is helping reduce the harms of covid-19.”

Proponents of widespread rapid testing note that it is important for controlling the pandemic because the other major diagnostic check for covid, the PCR test, can take days to process in a lab. An infectious person might spread the virus while waiting for results. Rapid antigen tests deliver results at home in 15 minutes but are somewhat less reliable, according to the Centers for Disease Control and Prevention.

Launched in late 2020 with private capital, eMed has 123 employees, with co-founder Dr. Patrice Harris, formerly the president of the American Medical Association, serving as its CEO and Dr. Helene Gayle, known for her groundbreaking work on HIV/AIDS at the Bill and Melinda Gates Foundation, as board chairperson.

Its president is Dr. Mitch Morris, formerly the head of Optum Advisory Services, UnitedHealth Group’s consulting arm.

EMed spokesperson Leigh Daniels declined to disclose the source of the company’s startup funding.

The company has signed deals with , , , and Massachusetts to make what it markets as “proctored” rapid tests widely available in those states and has to certify tests for travelers. In December, the CDC started allowing passengers entering the United States to prove covid negativity with a rapid test 鈥� but only if it is monitored and certified by eMed or another company.

After consumers are mailed Abbott Laboratories’ Binax tests, they swab their noses in an online session with an eMed monitor, who watches the process and verifies the results for a third party such as a school, an employer, or an airline.

“What’s so beautiful about eMed is that you can get tested at home, at your pool, your office, your studio, wherever you’re at,” musician DJ Khaled, signed as an eMed spokesperson, .

EMed made by Abbott in $150 six-packs, , on its site 鈥� twice as much as similar Abbott tests cost in a drugstore. The tests are $35 each 鈥� $70 for two 鈥� when monitored by eMed and bought through Quest Diagnostics, a large testing company.

Mina has criticized high test prices and argued that government tests. In other countries, rapid tests have sold for each.

Tests cost more on eMed’s site and on the Quest site because the price includes monitoring and confirmation by an eMed “certified guide,” Daniels said.

Joining eMed hasn’t changed his recommendations for low-cost testing, Mina said. Widely available rapid tests could even work to eMed’s disadvantage, if it prompted competition from other vendors or lowered demand for eMed’s testing services, he said.

Mina has been quoted or appeared on TV dozens of times since he made the switch from Harvard to entrepreneur, often with somewhat confusing attribution by the journalists.

He makes his new affiliation clear, he said. Journalists quoting or interviewing him often note his eMed connection but usually don’t mention that the company sells covid tests.

Besides planning to eventually manage other medical tests, such as for strep, eMed aims to speed treatment to patients who test positive and work with pharma companies testing new drugs in clinical trials, he said.

Some transparency advocates would like to see more in the way of disclosure: “I do think that journalists should be asking what type of interests someone might have that could be influencing the opinions that they’re expressing,” said Dr. Michael Carome, director of health research at Public Citizen, a left-leaning consumer advocacy organization.

Other experts who’ve moved into or partnered with industry have adopted their own strategies to navigate the boundary:

“My relationship to Pfizer is prominently disclosed in all my interactions with the media and I regularly make mention of it myself,” Gottlieb said in an email. “I am proud of the relationship and believe it is one element of my experience that informs my perspective and helps me contribute a unique voice to the broader dialogue.”

Birx was unavailable for comment, ActivePure spokesperson Jo Trizila said.

For Klausner’s part, advising Curative gives him a valuable, up-close perspective on attempts to fight the virus, he said.

“Some might think such activities might increase my credibility because I am actively working in the field dealing with real-world issues versus being an armchair epidemiologist,” he said.

Often professors consult for industry or own shares in startups while still holding academic positions, whereas Mina “has actually left Harvard,” said Carome. “Maybe that’s better. He’s not wearing that hat anymore.”

Mina, who was an , said he recognizes that scientists working for corporations might be viewed skeptically.

“When you go from Harvard to industry, it doesn’t matter who you are,” he said. “You lose some credibility in the public eye.”

But he said he sees more of a chance to make a difference with eMed than by staying in academia and publishing research.

Academia “just doesn’t allow you to build stuff. And I got frustrated with that,” he said. “I’ve always been drawn to building and doing rather than just doing papers.”

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The pregnancy went well until the surrogate experienced high blood pressure and other symptoms of preeclampsia, which could have harmed her and the babies. Doctors ordered an emergency delivery at 34 weeks’ gestation. Both infants had to spend more than a week in the neonatal intensive care unit.

It was April 2020, early in the pandemic. Unable to take a plane, the Bulls drove from their home in Huntington Beach, California, to the hospital in Provo, Utah. They had to quarantine in Utah before they could see the children in the hospital.

A couple of weeks later, after the babies could eat and breathe on their own, the Bulls took them home to California.

Then the bills came.

The Patients: Scarlett and Redford Bull, newborn twins covered by a Cigna policy sponsored by Greg Bull’s employer. The gestational surrogate had her own insurance, which covered her care.

Medical Service: Neonatal intensive care when the babies were born prematurely after emergency induced labor. Scarlett spent 16 days in the NICU; Redford, 10.

Total Bill: $117,084. The hospital was out of network for the infants. Cigna paid for some of Scarlett’s care, for reasons the Bulls couldn’t figure out. The Bulls were left on the hook for about $80,000, for both babies. Their account was ultimately sent to collections.

Service Provider: Utah Valley Hospital in Provo, Utah, one of 24 hospitals run by Intermountain Healthcare, a nonprofit with about in revenue.

What Gives: The Bulls’ ordeal points up a loophole in coverage for emergency care 鈥� even under the No Surprises Act, which took effect Jan. 1 and outlaws many kinds of surprise medical bills.

Patients who need prompt, lifesaving treatment often don’t have time to find an in-network hospital. In the past, health plans sometimes have said they would pay for emergency care even if it’s out of network. The No Surprises Act now makes this a legal requirement in every state. The provider and insurer are supposed to negotiate a reasonable payment, leaving the patient out of the equation.

But what if the insurance company denies that the care is for an emergency? Or the hospital doesn’t supply the paperwork to prove it?

That’s what happened to the Bulls. Cigna said it lacked documentation that the NICU care for the twins qualified as an emergency.

So the Bulls began receiving insurance explanations showing huge balances owed to Utah Valley. The family had expected to owe its out-of-network, out-of-pocket maximum of $10,000 for the twins’ care. They assumed most of the bills would be paid by Cigna soon. They weren’t.

“I was, like, there is no way this can be real,” said Sugar Bull, an interior designer.

“Dear Scarlett Bull,” began one of Cigna’s letters, addressed to a 6-month-old baby. “We found the service requested is not medically necessary.”

How could NICU care not qualify? The gestational surrogate was admitted to obstetrics by her doctor without going through the emergency department, which prompted Cigna to initially conclude there was no emergency, said Dylan Kirksey of Resolve Medical Bills, a consultancy that eventually worked with the Bulls to resolve the claims.

To establish that there was, Cigna asked for daily progress notes and other medical records on the infants. The Bulls tried to get the hospital to comply. Cigna kept saying it hadn’t received the necessary documentation.

The Bulls appealed. Sugar spent hours with insurance paperwork and hold music. But almost a year later, about $80,000 in bills remained. Utah Valley sent the accounts to collections, Sugar Bull said. It was the last thing she had time for.

“I own a company, and I am super busy, and we had twins,” she said. “Every two weeks or so, I would feel a panic and righteous anger about it. And I would keep pushing and calling, and it would take like five hours every time.”

Though they disputed what they were being charged, the Bulls agreed to pay the hospital $500 a month for five years to settle just one of the babies’ bills, in an attempt to keep their good credit.

Resolution: With seemingly nowhere else to turn, the family hired Resolve, which beats a path through the claims jungle in return for a portion of the money it saves clients.

“It was a lot of prodding” to get Utah Valley to give Cigna the information it needed to pay the hospital, said Kirksey, a senior advocate with Resolve, which was founded in 2019 and has 16 employees. He said he had to give the hospital a detailed list of steps to take and then follow up with multiple calls and emails per week.

In the end, most of the errors causing the Bulls’ nightmare were on the hospital’s side, Kirksey said. But instead of supplying what Cigna needed, Utah Valley went after the Bulls.

“The hospital repeatedly failed to provide a detailed list of services and important clinical information, despite our continuous efforts to secure the information,” said Cigna spokesperson Meaghan MacDonald.

“There were no errors on the hospital’s part,” said Utah Valley spokesperson Daron Cowley. “Utah Valley Hospital properly billed for services provided to the twins and provided the requested information to Cigna in a timely manner.”

The hospital didn’t bill the Bulls for outstanding balances until nine months after the twins were born and didn’t send the accounts to collections until six months after that, “after the family did not return the legally required paperwork to set up a payment plan,” he said.

Finally, in fall 2021, the bills were settled. The twins were 1陆 years old. To compensate Resolve for curing the balance, the Bulls paid the company about 10% 鈥� $8,000.

The fee, though substantial and unrelated to medical care, was worth it to avoid the much larger debt, said Greg Bull, who works in finance. “At the end of the day, it was such a relief for it to be a smaller amount,” he said. Still, many families could not have afforded it.

The Takeaway: About 1 in 5 emergency room visits are at facilities that are out of network for the patient’s insurance, . The No Surprises Act to cover non-network emergency treatment with the same patient cost sharing as in-network care. It also prohibits hospitals from billing patients extra.

But if the insurer denies that the care was for an emergency or doesn’t obtain documentation to prove it, the claim can still be rejected and the patient left on the hook.

“That’s a coding issue we see a lot,” said Kirksey, especially “if the person didn’t literally check in through the emergency room.”

Related Links

• The Doctor Didn’t Show Up, but the Hospital ER Still Charged $1,012
• NICU Bill Installment Plan: That’ll Be $45,843 a Month for 12 Months, Please
• The ER Charged Him $6,500 for Six Stitches. No Wonder His Critically Ill Wife Avoided the ER.

If this happens, insurance experts urge patients to immediately appeal the decision to the insurance company, a process the law requires to be available. Unfortunately, that usually requires more phone calls, paperwork, and waiting. (If the appeal with the insurer fails, patients can then turn to an independent reviewer, like their state insurance board, state attorney general’s office, or the .)

“It would be a critical step for the consumer to leverage their appeal rights 鈥� and get the determination that it was an emergency service from the get-go,” said Kevin Lucia, co-director of the Center on Health Insurance Reforms at Georgetown University.

Once it’s established that the visit was for an emergency, he said, protections from the No Surprises Act clearly apply.

The No Surprises Act is a step in the right direction. But it is clear that loopholes and minefields remain.

Stephanie O’Neill contributed the audio portrait with this story.

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Insurance covered most of the cost of the hospital stay, he said. He didn’t pay much attention to a bill he received from Commonwealth Anesthesia Associates and expected his insurance to cover it. A few months ago, he got a notice that Commonwealth was suing him in Richmond General District Court for $1,870 for putting him under during the surgery, court records show.

“Wow, seriously?” the 30-year-old information technology manager recalled thinking after getting the court summons. Loney didn’t have that kind of money at hand. His plan was to try to negotiate down the amount or “take out another credit card to pay for it.”

Loney’s is a classic, notorious type of surprise bill that Congress and activists have worked for years to eliminate: an out-of-network charge not covered by insurance even though the patient had an emergency procedure or sought care at an in-network hospital thinking insurance would cover most charges.

Commonwealth said it was in-network for Loney’s insurer, UnitedHealthcare. But the insurer rejected the anesthesiology charge because it said his primary care doctor was out of network, claims records show.

The federal No Surprises Act, passed at the end of 2020, has been hailed by consumer advocates for prohibiting such practices. Starting Jan. 1, medical companies in most cases cannot bill patients more than in-network amounts for any emergency treatment or out-of-network care delivered at an in-network hospital.

But as much as the legislation is designed to protect millions of patients from unexpected financial consequences, it will hardly spare all consumers from medical billing surprises.

“It’s great that there will be surprise billing protections 鈥� but you’re still going to see lawsuits,” said Zack Cooper, an economist and associate professor at the Yale School of Public Health. “This is by no means going to get rid of all of the problems with billing.”

The law will kick in too late for Loney and many others saddled with surprise out-of-network bills in states that don’t already ban the practice.

“It doesn’t prohibit surprise bills that are happening now in states that don’t have protections” against them, said Erin Fuse Brown, a law professor at Georgia State University who studies hospital billing. “And it doesn’t prohibit collection activity for surprise bills that arose prior to January.”

Virginia’s surprise-bill protection law took effect only this year and doesn’t apply to self-insured employer health plans, which cover a large portion of residents.

The federal legislation also does nothing to reduce another kind of unpleasant, often surprising bill 鈥� large, out-of-pocket payments for in-network medical care that many Americans can’t afford and might not have realized they were incurring.

Two substantial changes in recent years shifted more risk to patients. Employers and other payers narrowed their provider networks to exclude certain high-cost hospitals and doctors, making them out of network for more patients. They also drastically increased deductibles 鈥� the amount patients must pay each year before insurance starts contributing.

The No Surprises Act addresses the first change. It does nothing to address the second.

For a snapshot of the past and future of surprise and disputed medical bills, KHN examined Commonwealth’s lawsuits against patients in central Virginia and attended court hearings where patients contested their bills.

“The whole thing with insurance not covering my bills is a headache,” said Melissa Perez-Obregon, a Richmond-area dance teacher whom Commonwealth sued for $1,287 over services she received during the 2019 birth of her daughter, according to court records. Her insurance paid most but not all of a $5,950 anesthesia charge, billing records show.

“I’m a teacher,” she said, standing in the lobby at Chesterfield County General District Court. “I don’t have this kind of extra money.”

Commonwealth is one of the more active creditors seeking judgments in the Richmond area, court records show. From 2019 through 2021, it filed nearly 1,500 cases against patients claiming money owed for treatment, according to the KHN analysis of court filings.

In numerous cases, it initiated garnishment proceedings, in which creditors seize a portion of patients’ wages.

as “the largest private anesthesiology practice in Central Virginia,” Commonwealth said it employs more than 100 clinicians who care for roughly 55,000 patients a year in hospitals and surgery centers, mostly in the Richmond area.

Commonwealth said more than 99% of the patients it treats are members of insurance plans it accepts. It garnishes wages only as a “last resort” and only if the patient has the ability to pay, Michael Williams, Commonwealth’s practice administrator, said in a written statement.

“Over the past three years we have filed suit to collect from just over 1% of our patients,” mostly for money owed for in-network deductibles or coinsurance, Williams said. Nearly half the bills are settled before the court date, he said.

Gwendolyn Peters, 67, said she was shocked to receive a court summons this summer. Commonwealth was suing her for $1,000 for anesthesia during a lumpectomy for breast cancer in 2019, according to court records.

“This is the first time I have ever been in this situation,” she said, sitting in the Chesterfield court with half a dozen other Commonwealth defendants.

Because patients typically have little or no control over who puts them under, Brown said, anesthesiologists face less risk to their businesses and reputations than other medical specialists do in using aggressive collections tactics.

The specialty is often “one of the worst offenders because they don’t depend on their reputation to get patients,” she said. “They’re not going to lose business because they engage in these really aggressive practices that ruin their patients’ finances.”

The average annual deductible for single-person coverage from job-based insurance has soared from in the past 15 years, according to 麻豆女优. Deductibles for family coverage in many cases Coinsurance 鈥� the patient’s responsibility after the deductible is met 鈥� can add thousands of additional dollars in expenses.

That means millions of patients are essentially uninsured for care that might cost them a substantial portion of their income. Surveys have repeatedly found that many consumers say they would have an unexpected bill of even a few hundred dollars.

Loney’s insurer, UnitedHealthcare, agreed to pay the bill from Commonwealth for his emergency appendectomy after being contacted by KHN and saying it “updated” information on the claim. Otherwise, Loney said, he couldn’t have paid it without borrowing money.

In Richmond-area courthouses, hearings for Commonwealth lawsuits take place every few months. A lawyer for the anesthesiology practice attends, sometimes making payment arrangements with patients. Many defendants don’t show up, which often means they lose the case and might be subject to garnishment.

Commonwealth sued retiree Ronda Grimes, 66, for $1,442 for anesthesia claims her insurance didn’t cover after a 2019 surgery, billing and legal records filed in Richmond General District Court show.

“That’s a lot of money, especially when you have health insurance,” she said.

New examining court cases in Wisconsin shows that medical lawsuits are disproportionately filed against people of color and people living in low-income communities.

“Physicians are entitled to get paid like everyone else for their services,” Cooper said. But unaffordable, out-of-pocket medical costs are “a systemic issue. And this systemic issue generally falls on the backs of the most vulnerable in our population.”

For uninsured patients, Commonwealth matches any financial assistance given by the hospital and will be “enhancing” its financial assistance program in 2022, Williams said.

Two of the nine people being sued by Commonwealth and interviewed by KHN at courthouse hearings were Hispanic. Four were Black.

One was Darnetta Jefferson, 61, who underwent a double mastectomy in early 2020 and came to court wearing a cancer-survivor shirt. Commonwealth sued her for $836 it said she owed in coinsurance for anesthesia she was given during the surgery. Commonwealth’s lawyer agreed to drop the lawsuit if she agreed to pay $25 a month toward the balance until it’s paid, she said.

“If I ever have some extra money to pay it off someday, I will,” said Jefferson, who worked at Ukrop’s supermarket for many years before her cancer forced her to go on disability. “But right now, my circumstances are not looking good.”

Although she is living on a reduced income, her rent just went up again, said Jefferson, who also survived lung cancer diagnosed in 2009. Rent now runs close to $1,000 a month.

Paying Commonwealth’s bill in monthly $25 increments, she said, means “it’s going to be a long way to go.”

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The child failed the screening required by law for all newborns, the tester said, requiring a follow-up exam. “We were scared as first-time parents,” said Malik, who agreed to the second exam. The clinician, Malik said, didn’t tell them that infants often fail an initial screening because of in the ears that soon dissipates. The second screening found no problem with the baby’s hearing.

Last year, when her second daughter was born, Malik refused a hearing test after another Pediatrix clinician appeared at her bedside. (Parents are allowed to opt out but rarely do.)

The infant hearing test 鈥� particularly the more advanced technology Pediatrix uses 鈥� is an example of how some common medical procedures have become significantly more profitable for their providers.

Pediatrix and related companies have drawn a string of complaints from dissatisfied customers like Malik, who said she was surprised by Pediatrix’s charges for in-hospital infant care. Such tests were once free or included in a hospital’s new-baby fees. Pediatrix earns tens of millions of dollars a year in revenue from them, according to regulatory filings.

Founded in Florida decades ago, Pediatrix and its parent company, Mednax, have grown into a network of physicians and other clinicians delivering hearing screens, pediatric intensive care, pediatric surgery and obstetric services. They operate in more than 400 affiliated hospitals in some 40 states.

Pediatrix now cares for about 1 in 4 babies in neonatal intensive care units, according to the company, and administers its hearing tests to nearly a million babies a year.

“I’ve been involved with trying to prevent them coming into hospitals,” said Lisa Hunter, a professor and pediatric hearing specialist at the University of Cincinnati who objected generally to Pediatrix’s high charges for hearing screens and the billing confusion they can cause. “I’m very much empathetic with patients who have concerns.”

Pediatrix officials say their doctors and other clinicians deliver top-level maternity and newborn medicine, often to smaller and community hospitals as well as large systems, providing not just hearing tests but surgery and lifesaving care for premature babies.

“Doing what’s right for the patient is our highest priority,” said Dr. Roger Hinson, president of the Pediatrix and Obstetrix medical group.

Dr. Michelle Barhaghi, an obstetrician herself, said she was shocked by the $6,538 that a Pediatrix doctor in California charged for the unplanned cesarean delivery of her baby in April while she was traveling.

“When I saw that, my jaw dropped,” she said. “I sent that bill statement to all my OB-GYN friends.”

Insurance paid Pediatrix $2,867, according to benefit statements. That’s still nearly three times the rate for the same procedure under Medicare’s schedule of physician fees. Pediatrix also billed Barhaghi $1,311 for charges that insurance didn’t cover for a physical and discharge prep for her baby. Pediatrix withdrew that bill after being contacted by KHN for comment, she said.

Three years ago, the insurance giant Aetna sued Mednax and Pediatrix, saying they inflated charges by more than $50 million, performing unneeded tests and treatments and diagnosing babies as being sicker than they really were.

Mednax denied Aetna’s allegations, and the case ended in July when Aetna withdrew it as part of a confidential agreement. Neither Aetna nor Mednax would disclose the terms.

As part of the proceedings, Mednax admitted in court that it destroyed internal emails Aetna had sought as potential evidence of corporate coaching to nudge physicians to engage in “upcoding” to higher-value procedures.

Pediatrix was a of a campaign in the early 2000s for state laws requiring hearing tests for babies, records show. now have such laws, and the American Academy of Pediatrics for all newborns before they leave the hospital.

The idea is that the rare baby with hearing deficiencies 鈥� two or three in every thousand 鈥� needs to be identified quickly to ensure proper treatment and language development even if some false positives worry parents.

A simple screen measures whether the baby’s inner ear responds to sound. A more expensive hearing screen, a procedure originally designed to assess patients with serious neurological or auditory disease, measures the brain’s electrical response to sound.

Many hospitals reserve that screen for high-risk babies in intensive care or for those who fail an earlier, less expensive screening.

Aetna’s claims analysis found that Mednax and affiliates billed three times more often for those kinds of tests than for those given by non-Mednax clinicians.

Pediatrix charges $150 or more for the test, said audiologists familiar with the company. The company charged $326 for Malik’s first child’s screening, billing records show, and insurance paid a discounted price of $177.

“The cost of doing the screening should be no more than $50,” said professor Hunter, including the initial test and in-hospital follow-up. “To bill more than that, and to do this on every single baby that’s born, to me that sounds like a license to print money.”

Hinson said Pediatrix uses the more expensive auditory brainstem screen because it tests the entire hearing pathway. He said it has a lower false-positive rate on infant screenings than the less expensive alternative.

The Joint Committee on Infant Hearing, a board of experts considered authoritative for screening protocols, says initially for babies.

But done in the hospital soon after birth, both varieties produce a substantial number of initial false indications of hearing deficiency, , often because of fluid in the ears from birthing.

This requires a second test either in the hospital or sometimes weeks later in a doctor’s office. Meanwhile, families might believe their baby could be deaf. When parents are approached by an infant-hearing screener in the hospital, they should make sure the procedure is covered by insurance, patient advocates say. If the child fails the test, parents should be aware it could be a fleeting result and request a follow-up before leaving the hospital.

or mishandled bills from Pediatrix and Mednax have drawn complaints to the Better Business Bureau and on .

When a Mednax or Pediatrix clinician is outside a patient’s insurance network, “we bill the balance to the patient,” the company says in filings with the Securities and Exchange Commission. At least one hospital, Inova Alexandria Hospital in Northern Virginia, has warned expectant parents that Pediatrix “may not be an approved provider” with their insurer.

From the beginning of 2019 to mid-November, 192 people filed complaints with the Better Business Bureau against Pediatrix and Mednax, according to data provided by the BBB. Most of the complaints are about billing and collections issues, according to the data.

“We have to do things that make things more seamless for our patients and more seamless for our payers,” Hinson said. When Pediatrix is out of network, the company works with families “to mitigate post-discharge surprise billing,” he said.

It took more than a year, two dozen phone calls and the help of the Better Business Bureau to resolve one incorrect $1,010 bill. It was charged for a Pediatrix nurse practitioner who stood by while Sarah Tela’s twins were delivered by an obstetrician in 2018.

After doing research, Tela, who lives near Seattle, realized that “I wasn’t the only one going through this battle with them.” She added: “I could have easily paid the bill. But I knew I was right.”

The problem turned out to be an incorrect date of service on the bill, which caused the insurer’s claims software to reject it, she said.

Mednax, which contacted Barhaghi and Malik after their cases were brought up by a reporter, is “confident that their respective matters are being resolved to their satisfaction,” the company said in an email.

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Anthem, like other big insurers, is using the covid-19 crisis as cover to institute “egregious” policies that harm patients and pinch hospital finances, said Molly Smith, group vice president at the American Hospital Association. “There’s this sense of 鈥楨veryone’s distracted. We can get this through,’” she said.

Hospitals are also dealing with a spike in retroactive claims denials by UnitedHealthcare, the biggest health insurer, for emergency department care, AHA says.

Disputes between insurers and hospitals are nothing new. But this fight sticks more patients in the middle, worried they’ll have to pay unresolved claims. Hospitals say it is hurting their finances as many cope with covid surges 鈥� even after the industry has received tens of billions of dollars in emergency assistance from the federal government.

“We recognize there have been some challenges” to prompt payments caused by claims-processing changes and “a new set of dynamics” amid the pandemic, Anthem spokesperson Colin Manning said in an email. “We apologize for any delays or inconvenience this may have caused.”

Virginia law requires . In a Sept. 24 letter to state insurance regulators, VCU Health, a system that operates a large teaching hospital in Richmond associated with Virginia Commonwealth University, said Anthem owes it $385 million. More than 40% of the claims are more than 90 days old, VCU said.

For all Virginia hospitals, Anthem’s late, unpaid claims amount to “hundreds of millions of dollars,” the Virginia Hospital and Healthcare Association said in a June 23 letter to state regulators.

Nationwide, the payment delays “are creating an untenable situation,” the American Hospital Association said in a Sept. 9 letter to Anthem CEO Gail Boudreaux. “Patients are facing greater hurdles to accessing care; clinicians are burning out on unnecessary administrative tasks; and the system is straining to finance the personnel and supplies” needed to fight covid.

Complaints about Anthem extend “from sea to shining sea, from New Hampshire to California,” AHA CEO Rick Pollack told KHN.

Substantial payment delays can be seen on Anthem’s books. On June 30, 2019, before the pandemic, 43% of the insurer’s medical bills for that quarter were unpaid, according to regulatory filings. Two years later that figure had risen to 53% 鈥� a difference of $2.5 billion.

Anthem profits were $4.6 billion in 2020 and $3.5 billion in the first half of 2021.

Alexis Thurber, who lives near Seattle, was insured by Anthem when she got an $18,192 hospital bill in May for radiation therapy that doctors said was essential to treat her breast cancer.

The treatments were “experimental” and “not medically necessary,” Anthem said, according to Thurber. She spent much of the summer trying to get the insurer to pay up 鈥� placing two dozen phone calls, spending hours on hold, sending multiple emails and enduring unmeasurable stress and worry. It finally covered the claim months later.

“It’s so egregious. It’s a game they’re playing,” said Thurber, 51, whose cancer was diagnosed in November. “Trying to get true help was impossible.”

Privacy rules prevent Anthem from commenting on Thurber’s case, said Anthem spokesperson Colin Manning.

When insurers fail to promptly pay medical bills, patients are left in the lurch. They might first get a notice saying payment is pending or denied. A hospital might bill them for treatment they thought would be covered. Hospitals and doctors often sue patients whose insurance didn’t pay up.

Hospitals point to a variety of Anthem practices contributing to payment delays or denials, including new layers of document requirements, prior-authorization hurdles for routine procedures and requirements that doctors themselves 鈥� not support staffers 鈥� speak to insurance gatekeepers. “This requires providers to literally leave the patient[’s] bedside to get on the phone with Anthem,” AHA said in its letter.

Anthem often hinders coverage for outpatient surgery, specialty pharmacy and other services in health systems listed as in-network, amounting to a “bait and switch” on Anthem members, AHA officials said.

“Demanding that patients be treated outside of the hospital setting, against the advice of the patient’s in-network treating physician, appears to be motivated by a desire to drive up Empire’s profits,” the Greater New York Hospital Association wrote in an April letter to Empire Blue Cross, which is owned by Anthem.

Anthem officials pushed back in a recent letter to the AHA, saying the insurer’s changing rules are intended partly to control excessive prices charged by hospitals for specialty drugs and nonemergency surgery, screening and diagnostic procedures.

Severe problems with Anthem’s new claims management system surfaced months ago and “persist without meaningful improvement,” AHA said in its letter.

Claims have gotten lost in Anthem’s computers, and in some cases VCU Health has had to print medical records and mail them to get paid, VCU said in its letter. The cash slowdown imposes “an unmanageable disruption that threatens to undermine our financial footing,” VCU said.

United denied $31,557 in claims for Emily Long’s care after she was struck in June by a motorcycle in New York City. She needed surgery to repair a fractured cheekbone. United said there was a lack of documentation for “medical necessity” 鈥� an “incredibly aggravating” response on top of the distress of the accident, Long said.

The Brooklyn hospital that treated Long was “paid appropriately under her plan and within the required time frame,” said United spokesperson Maria Gordon Shydlo. “The facility has the right to appeal the decision.”

United’s unpaid claims came to 54% as of June 30, about the same level as two years previously.

When Erin Conlisk initially had trouble gaining approval for a piece of medical equipment for her elderly father this summer, United employees told her the insurer’s entire prior-authorization database had gone down for weeks, said Conlisk, who lives in California.

“There was a brief issue with our prior-authorization process in mid-July, which was resolved quickly,” Gordon Shydlo said.

When asked by Wall Street analysts about the payment backups, Anthem executives said it partly reflects their decision to increase financial reserves amid the health crisis.

“Really a ton of uncertainty associated with this environment,” John Gallina, the company’s chief financial officer, said on a conference call in July. “We’ve tried to be extremely prudent and conservative in our approach.”

During the pandemic, hospitals have benefited from two extraordinary cash infusions. They and other medical providers have received more than $100 billion through the CARES Act of 2020 and the American Rescue Plan of 2021. Last year , and other insurers accelerated billions in hospital reimbursements.

The federal payments while serving low-income patients and rural areas struggled.

Those are the systems most hurt now by insurer payment delays, hospital officials said. Federal relief funds “have been a lifeline, but they don’t make people whole in terms of the losses from increased expenses and lost revenue as a result of the covid experience,” Pollack said.

Several health systems declined to comment about claims-payment delays or didn’t respond to a reporter’s queries. Among individual hospitals “there is a deep fear of talking on the record about your largest business partner,” AHA’s Smith said.

Alexis Thurber worried she might have to pay her $18,192 radiation bill herself, and she’s not confident her Anthem policy will do a better job next time of covering the cost of her care.

“It makes me not want to go to the doctor anymore,” she said. “I’m scared to get another mammogram because you can’t rely on it.”

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By making prohibitively expensive medicine essentially free for patients, the company induced them to use Pfizer drugs even as the price of one of those medicines, covered by Medicare and Medicaid, soared 44% to $225,000 a year, the Justice Department alleged.

Now Pfizer is suing Uncle Sam to legalize essentially the same practice it was accused of three years ago 鈥� a fighting response to a federal crackdown that has resulted in a dozen drug companies being accused of similar practices.

A Pfizer win could cost taxpayers billions of dollars and erase an important control on pharma marketing after decades of regulatory erosion and soaring drug prices, say health policy analysts. A federal judge’s ruling is expected any day.

“If this is legal for Pfizer, Pfizer will not be the only pharmaceutical company to use this, and there will effectively be a gold rush,” government lawyer Jacob Lillywhite said in oral arguments last month.

Pfizer’s legal argument “is aggressive,” said Chris Robertson, a professor of health law at Boston University. “But I think they’ve got such a political tailwind behind them” because of pocketbook pain over prescription medicine 鈥� even though it’s caused by pharma manufacturers. Pfizer’s message, “鈥榃e’re just trying to help people afford their drugs,’ is pretty attractive,” he said.

That’s not all that’s working in Pfizer’s favor. Courts and regulations have been moving pharma’s way since the Food and Drug Administration allowed limited TV drug ads in the 1980s. Other companies of all kinds also have gained free speech rights allowing aggressive marketing and political influence that would have been unthinkable decades ago, legal scholars say.

Among other court arguments, Pfizer initially claimed that current regulation violates its speech protections under the First Amendment, essentially saying it should be allowed to communicate freely with third-party charities to direct patient assistance.

“It’s infuriating to realize that, as outlandish as they seem, these types of claims are finding a good deal of traction before many courts,” said Michelle Mello, a professor of law and medicine at Stanford University. “Drug companies are surely aware that the judicial trend has been toward more expansive recognition of commercial speech rights.”

Pfizer’s lawsuit, in the Southern District of New York, seeks a judge’s permission to directly reimburse patient expenses for two of its heart-failure drugs each costing $225,000 a year. An outside administrator would use Pfizer contributions to cover Medicare copays, deductibles and coinsurance for those drugs, which otherwise would cost patients about $13,000 a year.

Letting pharma companies put money directly into patients’ pockets to pay for their own expensive medicines “does induce people to get a specific product” instead of shopping for a cheaper or more effective alternative, said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University. “It’s kind of the definition of a kickback.”

Government rule-makers have since the launch of Medicare’s Part D drug benefit in 2006. Drug companies routinely help privately insured patients with cost sharing through coupons and other means, but private carriers can negotiate the overall price.

Because Congress gave Medicare no control over prescription drug prices, having patients share at least part of the cost is the only economic force guarding against unlimited price hikes and industry profits at taxpayer expense.

At the same time, however, regulators have allowed the industry to help patients with copays by routing money through outside charities 鈥� but only as long as the charities are “ that don’t match drugmaker money with specific drugs.

Several charities have blatantly violated that rule in recent years by colluding with pharma companies to subsidize particular drugs, the Justice Department has alleged. A dozen companies have paid more than $1 billion to settle allegations of kickback violations.

Pfizer set up an internal fund at one of the charities, the Patient Access Network Foundation, to cover patient costs for a heart arrhythmia drug at exactly the same time it was raising the wholesale cost from $220 to $317 for a package of 40 capsules, . Pfizer referred Medicare patients who needed the drug to the PAN Foundation, the government said.

Under such arrangements, every $1 million channeled through a charity “has the potential to generate up to $21 m[illion] for the sponsor company, funded by the U.S. government,” Andrew Baum, a Citi pharma stock analyst, wrote in 2017.

Pfizer settled the case, saying it was not an admission of wrongdoing but resulted from its “desire to put this legal matter behind us.”

and three also made deals to resolve allegations that they functioned as disallowed conduits for patient assistance for multiple pharma companies. One organization, the Virginia-based Caring Voice Coalition, shut down after government scrutiny.

PAN’s settlement did not mention the alleged Pfizer transactions. Those were described in the separate government deal with Pfizer.

The 2019 PAN agreement related to “legacy matters” and “did not involve any of PAN’s current operations or disease funds,” organization CEO Dan Klein said via a spokesperson. “Nonprofit patient assistance programs like PAN are necessary to help people access the critical medications they need to stay healthy.”

But legal troubles have hardly slowed the pharma-funded patient assistance business.

Four penalized nonprofits agreed to stop directing money to specific drugs, but they continue to accept hundreds of millions of dollars in pharma donations to indirectly cover copays and other patient drug costs, organization reports and IRS filings show. HHS regulators allow the practice because the drug companies are not involved in deciding which patients and which drugs are subsidized.

Donations to six pharma-funded patient assistance charities reached $1.8 billion in 2019, only slightly less than the year before, a KHN analysis of their IRS filings shows. That was nearly 50% higher than the amount from five years previously, before the Justice Department started cracking down.

Last year Pfizer donated $39.7 million to PAN and five other charities helping patients with out-of-pocket drug costs, company disclosures show.

If Pfizer’s lawsuit seeking to earmark such donations for its tafamidis heart-failure drugs opens the way for similar practices industrywide, it would drive up Medicare costs through rising prices and numbers of prescriptions, said Gerard Anderson, an economist and health policy professor at Johns Hopkins University’s Bloomberg School of Public Health. Such a program for tafamidis alone would increase Medicare costs by $30 billion, the Health and Human Services Department’s inspector general estimated.

Pharma companies can “learn which patients are using the drug, and they can market [and offer financial assistance] directly to that patient,” Anderson said. “You get a huge return.”

Pfizer argues that its proposal, which the HHS inspector general called “highly suspect” in an advisory opinion before the company filed its lawsuit, is legal and sensible.

“Providing copay assistance to middle-income patients who have been prescribed tafamidis is an efficient and equitable way to lower their out-of-pocket costs,” company spokesperson Steven Danehy said.

But the real affordability problem for patients is that tafamidis is too expensive, federal attorney Lillywhite said in court arguments last month. (HHS’ Office of Inspector General declined to comment.)

Pfizer has “priced itself out of the market,” he said. The company is seeking to “do something that’s unprecedented, to upend decades of settled law and agency guidance” to boost sales of “what is the most expensive cardiovascular drug ever launched in the United States.”

After the oral arguments, Pfizer dropped claims that HHS rules violate its free speech rights. Judge Mary Kay Vyskocil is considering only the company’s contention that a dedicated fund for tafamidis would not violate kickback prohibitions because, among other arguments, it is the doctor who decides to prescribe the drug and create revenue for Pfizer, not the patient getting the financial assistance.

But legal analysts still see the case as part of a broad movement toward deregulation and corporate rights.

A 1970s Supreme Court case, viewed as paving the way for an explosion of drug, lawyer and liquor ads as well as corporate campaign donations, was about speech rights for prescription drug sellers in Virginia. In 2011 the court found that the First Amendment allows data miners to buy and sell prescription records from pharmacies, provided the patients aren’t identified.

A year later, a federal appeals court cited speech protections when it overturned the conviction of a pharma sales rep who had been promoting a drug for uses not approved by the FDA.

Even if Pfizer loses its case, the climate may be ripe for similar challenges by other drugmakers, especially after the appointment of more than 200 federal judges by business-friendly President Donald Trump, legal scholars said.

The federal kickback law doesn’t mention copay assistance charities “and wasn’t designed with these programs in mind,” said Mello, of Stanford. Pfizer’s lawsuit “should be a loud, clanging call to Congress” to explicitly define drug assistance subsidies as illegal kickbacks, she said.

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The bill was extraordinary. Sutter Health Memorial Medical Center charged $44,914 including an $8,928 “trauma alert” fee, billed for summoning the hospital’s top surgical specialists and usually associated with the most severely injured patients.

The case, buried in the records of a 2017 trial, is a rare example of a courtroom challenge to something billing consultants say is increasingly common at U.S. hospitals.

Tens of thousands of times a year, hospitals charge enormously expensive trauma alert fees for injuries so minor the patient is never admitted.

In Florida alone, where the number of trauma centers has exploded, hospitals charged such fees more than 13,000 times in 2019 even though the patient went home the same day, according to a KHN analysis of state data provided by Etienne Pracht, an economist at the University of South Florida. Those cases accounted for more than a quarter of all the state’s trauma team activations that year and were more than double the number of similar cases in 2014, according to an all-payer database of hospital claims kept by Florida’s Agency for Health Care Administration.

While false alarms are to be expected, such frequent charges for little if any treatment suggest some hospitals see the alerts as much as a money spigot as a clinical emergency tool, claims consultants say.

“Some hospitals are using it as a revenue generator,” Tami Rockholt, a registered nurse and medical claims consultant who appeared as an expert witness in the Sutter Health car-accident trial, said in an interview. “It’s being taken advantage of” and such cases are “way more numerous” than a few years ago, she said.

Hospitals can charge trauma activation fees when a crack squad of doctors and nurses assembles after an ambulance crew says it’s approaching with a patient who needs trauma care. The idea is that life-threatening injuries need immediate attention and that designated trauma centers should be able to recoup the cost of having a team ready 鈥� even if it never swings into action.

Those fees, which can exceed $50,000 per patient, are billed on top of what hospitals charge for emergency medical care.

“We do see quite a bit of non-appropriate trauma charges 鈥� more than you’d see five years ago,” said Pat Palmer, co-founder of Beacon Healthcare Costs Illuminated, which analyzes thousands of bills for insurers and patients. Recently “we saw a trauma activation fee where the patient walked into the ER” and walked out soon afterward, she said.

The portion of Florida trauma activation cases without an admission rose from 22% in 2012 to 27% last year, according to the data. At one Florida facility, Broward Health Medical Center, there were 1,285 trauma activation cases in 2019 with no admission 鈥� almost equal to the number that led to admissions.

“Trauma alerts are activated by EMS [first responders with emergency medical services], not hospitals, and we respond accordingly when EMS activates a trauma alert from the field,” said Jennifer Smith, a Broward Health spokesperson.

Florida regulations allow hospitals themselves to declare an “in-hospital trauma alert” for “patients not identified as a trauma alert” in the field, according to by the Florida Department of Health.

At some hospitals, few patients whose cases generate trauma alerts are treated and released the same day.

At Regions Hospital, a Level I trauma center in St. Paul, Minnesota, patients who are not admitted after a trauma team alert are “very rare” 鈥� 42 of 828 cases last year, or about 5%, said Dr. Michael McGonigal, the center’s director, who blogs at “.”

“If you’re charging an activation fee for all these people who go home, ultimately that’s going to be a red flag” for Medicare and insurers, he said.

In the Sutter case in Modesto, the patient sued a driver who struck his vehicle, seeking damages from the driver and her insurer. Patient “looks good,” an emergency doctor wrote in the records, which were part of the trial evidence. He prescribed Tylenol with hydrocodone for pain.

“If someone is not going to bleed out, or their heart is not going to stop, or they’re not going to quit breathing in the next 30 minutes, they probably do not need a trauma team,” Rockholt said in her testimony.

Like other California hospitals with trauma center designations, Sutter Health Memorial Medical Center follows “county-designated criteria” for calling an activation, said Sutter spokesperson Liz Madison: “The goal is to remain in position to address trauma cases at all times 鈥� even in the events where a patient is determined healthy enough to be treated and released on the same day.”

Trauma centers regularly review and revise their rules for trauma team activation, said Dr. Martin Schreiber, trauma chief at Oregon Health & Science University and board chair at the Trauma Center Association of America, an industry group.

“It is not my impression that trauma centers are using activations to make money,” he said. “Activating patients unnecessarily is not considered acceptable in the trauma community.”

Hospitals began billing trauma team fees to insurers of all kinds after Medicare authorized them for cases in which hospitals are notified of severe injuries before a patient arrives. Instead of leaving trauma team alerts to the paramedics, hospitals often call trauma activations themselves based on information from the field, trauma surgeons say.

Reimbursement for trauma activations is complicated. Insurers don’t always pay a hospital’s trauma fee. Under rules established by Medicare and a committee of insurers and health care providers, emergency departments must give 30 minutes of critical care after a trauma alert to be paid for activating the team. For inpatients, the trauma team fee is sometimes folded into other charges, billing consultants say.

But, on the whole, the increase in the size and frequency of trauma team activation fees, including those for non-admitted patients, has helped turn trauma operations, often formerly a financial drain, into profit centers. In recent years, hundreds of hospitals have sought trauma center designation, which is necessary to bill a trauma activation fee.

“There must have been a consultant that ran around the country and said, 鈥楬ey hospitals, why don’t you start charging this, because you can,’” said Marc Chapman, founder of , which challenges large hospital bills for auto insurers and other payers. “In many of those cases, the patients are never admitted.”

The national number of Level I and Level II trauma centers, able to treat the most badly hurt patients, grew from 305 in 2008 to 567 last year, according to the American College of Surgeons. Hundreds of other hospitals have Level III or Level IV trauma centers, which can treat less severe injuries and also bill for trauma team activation, although often at lower rates.

Emergency surgeons say they walk a narrow path between being too cautious and activating a team unnecessarily (known as “overtriage”) and endangering patients by failing to call a team when severe injuries are not obvious.

Often “we don’t know if patients are seriously injured in the field,” said Dr. Craig Newgard, a professor of emergency medicine at Oregon Health & Science University. “The EMS providers are using the best information they have.”

Too many badly hurt patients still don’t get the care they need from trauma centers and teams, Newgard argues.

“We’re trying to do the greatest good for the greatest number of people from a system perspective, recognizing that it’s basically impossible to get triage right every time,” he said. “You’re going to take some patients to major trauma centers who don’t really end up having serious injury. And it’s going to be a bit more expensive. But the trade-off is optimizing survival.”

At Oregon Health & Science, 24% of patients treated under trauma alerts over 12 months ending this spring were not admitted, Schreiber said.

“If this number gets much lower, you could put patients who need activation at risk if they are not activated,” he said.

On the other hand, rising numbers of trauma centers and fees boost health care costs. The charges are passed on through higher insurance premiums and expenses paid not just by health insurers but also auto insurers, who often are first in line to pay for the care of a crash victim.

Audits are uncommon and often the system is geared to paying claims with little or no scrutiny, billing specialists say. Legal challenges like the one in the Sutter case are extremely rare.

“Most of these insurers, especially auto insurance, do not look at the bill,” said Beth Morgan, CEO of Medical Bill Detectives, a consulting firm that helps insurers challenge hospital charges. “They automatically pay it.”

And trauma activation charges also can hit patients directly.

“Sometimes the insurance companies will not pay for them. So people could get stuck with that bill,” Morgan said.

A few years ago, Zuckerberg San Francisco General Hospital charged a $15,666 trauma response fee to the family of a toddler who had fallen off a hotel bed. He was fine. Treatment was a bottle of formula and a nap. The hospital waived the fee after KHN and Vox wrote about it.

Trauma alert fatigue can add up to a nonfinancial cost for the trauma team itself, McGonigal said.

“Every time that pager goes off, you’re peeling a lot of people away from their jobs only to see [patients] go home an hour or two later,” he said.

“Some trauma centers are running into problems because they run themselves ragged. And there is probably unneeded expense in all the resources that are needed to evaluate and manage those patients.”

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But Knight’s wound, while requiring about 30 stitches, wasn’t life-threatening. Hospital records called it “mild.” The people in white coats quickly scattered, he remembered, and he went home about three hours later.

“Basically, it was just a gash on my arm,” said Knight, 71. “The emergency team that they assembled didn’t really do anything.”

Nevertheless, Chippenham, owned by for-profit chain HCA Healthcare, included a $17,000 trauma team “activation” fee on Knight’s bill, which totaled $52,238 and included three CT scans billed at $14,000. His care should have cost closer to $3,500 total, according to claims consultant WellRithms, which analyzed the charges for KHN.

HCA Healthcare’s activation fees run as high as $50,000 per patient and are sometimes 10 times greater than those at other hospitals, according to publicly posted price lists. Such charges have made trauma centers, once operated mainly by established teaching hospitals, a key part of the company’s growth and profit-generating strategy, corporate officials have said. HCA’s stock has doubled in three years. The biggest U.S. hospital operator along with the Department of Veterans Affairs, HCA has opened trauma centers in more than half its 179 hospitals and in the country.

And it’s not slowing down.

HCA “has basically taken a position that all of their hospitals should be trauma centers,” said Dr. Robert Winchell, describing conversations he had with HCA officials. Winchell is a trauma surgeon and former chairman of the at the American College of Surgeons.

Trauma patients are typically those severely injured in automobile accidents or falls or wounded by knives or guns.

State or local regulators confer the designation “trauma center,” often in concert with standards verified by the American College of Surgeons. The status allows a cascade of lucrative reimbursement, including activation fees billed on top of regular charges for medical care. Trauma centers are mostly exempt from enacted to limit excessive hospital spending and expansion. The bills for all this 鈥� reaching into tens of thousands of dollars 鈥� go to private insurers, Medicare or Medicaid, or patients themselves.

“Once a hospital has a trauma designation, it can charge thousands of dollars in activation fees for the same care seen in the same emergency room,” said Stacie Sasso, executive director of the Health Services Coalition, made up of unions and employers fighting trauma center expansion by HCA and others in Nevada.

HCA’s expansion into trauma centers alarms health policy analysts who suggest its motive is more about chasing profit than improving patient care. Data collected by the state of Florida, analyzed by KHN, shows that regional trauma cases and expensive trauma bills rise sharply after HCA opens such centers, suggesting that many patients classified as trauma victims would have previously been treated less expensively in a regular emergency room.

Patients admitted to HCA and other for-profit hospitals in Florida with a trauma-team activation were far more likely to be only mildly or moderately injured than those at not-for-profit hospitals, .

HCA is “cherry-picking patients,” said , CEO of the University of Florida Health Shands, which runs a Level I trauma center, the highest designation. “What you find is an elderly person who fell and broke their hip who could be perfectly well treated at their local hospital now becomes a trauma patient.”

HCA’s trauma center expansion makes superior care available to more patients, providing “lifesaving clinical services while treating all critically injured patients,” said company spokesperson Harlow Sumerford.

Richmond’s population “is booming,” said Chippenham spokesperson Jeffrey Caldwell. “This increase in demand requires that the regional health care system keep up.”

Trauma Is Big Business

HCA’s trauma center boom picked up speed in Florida a decade ago and has spread to its hospitals in Virginia, Nevada, Texas and other states. It has sparked fierce fights over who handles highly profitable trauma cases and debates over when rival centers go head-to-head competing for patients.

“There’s no question it’s a money grab” by HCA, said Jimenez, who was part of a largely unsuccessful effort to stop HCA’s trauma center expansion in Florida. “It was clear that their trauma activation fees were five or six times larger than ours.”

In a process shielded from public view in Virginia, Chippenham recently applied for and won the highest trauma center designation, Level I, providing the most sophisticated care 鈥� and putting it squarely in competition with nearby VCU Health. VCU has run the region’s only Level I facility for decades. In October, Chippenham announced a contract for its own helicopter ambulance, which gives it another way to increase its trauma business, by flying patients in from miles away. The Virginia Department of Health rejected KHN’s request to review HCA’s Chippenham trauma center application and related documents.

“This is a corporate strategy” by HCA “to grow revenue, maximize reimbursement and meet the interest of stockholders,” said Dr. Arthur Kellermann, CEO of VCU Health, who says his nonprofit, state-run facility is sufficient for the region’s trauma care needs. “Many people in the state should be concerned that the end result will be a dilution of care, higher costs and poorer outcomes.”

Chippenham’s Caldwell said the “redundancy” with VCU “allows the region to be better prepared for mass trauma events.”

Studies show trauma centers need high volumes of complex cases to stay sharp. Researchers call it the “practice makes perfect” effect. Patients treated for traumatic brain injuries at hospitals seeing fewer than six such cases a year died at substantially higher rates than such patients in more experienced hospitals,

Another study, , showed that a decrease as small as 1% in trauma center volume 鈥� because of competition or other reasons 鈥� substantially increased the risk that patients would die.

By splitting a limited number of cases, a competing, cross-town trauma center could set the stage for subpar results at both hospitals, goes the argument. The number of VCU’s admitted adult trauma patients decreased from nearly 3,600 in 2014, before Chippenham attained Level II status, to 3,200 in 2019, VCU officials said.

Chippenham was the only Level I center in Virginia that declined to disclose its trauma patient volume to KHN.

“People are trying to push the [trauma center] designation process beyond what may be good for the major hospitals that are already providing trauma care,” said Dr. David Hoyt, executive director of the American College of Surgeons, speaking generally. Local authorities who make those decisions, he said, can be “pressured by a hospital system that has a lot of economic pull in a community.”

Unlike regular emergency departments, Level I and Level II trauma surgeons, neurosurgeons and special equipment available round-the-clock. Centers with Levels III or IV designations offer fewer services but are still more capable than many emergency rooms, with round-the-clock lab services and extra training, for example.

Hospitals defend trauma team activation fees as necessary to cover the overhead of having a team of elite emergency specialists at the ready. At HCA hospitals they can run more than $40,000 per case, according to publicly posted charge lists, although the amount paid by insurers and patients is often less, depending on the coverage.

“Fees associated with trauma activation are based on our costs to immediately deploy lifesaving resources and measures 24/7,” said HCA spokesperson Sumerford, adding that low-income and uninsured patients often pay nothing for trauma care. “What patients actually pay for their hospital care has more to do with their insurance plan” than the total charges, he said.

There is no standard accounting for trauma-related costs incurred by hospitals. One method involves for members of the trauma team by the potential hours worked. Hospitals don’t reveal calculations, but the wide variation in fees suggests they are often set with an eye on revenue rather than true costs, say industry analysts.

Reasonable charges for Knight’s total bill would have been $3,537, not $52,238, according to the analysis by WellRithms, a claims consulting firm that examined his medical records and Chippenham’s costs filed with Medicare. Given his minor injury, the $17,000 trauma activation fee “is not necessary,” said Dr. Ira Weintraub, WellRithms’ chief medical officer.

Often insurers pay substantially less than billed charges, especially Medicare, Knight's insurer. He paid nothing out-of-pocket, and Chippenham collected a total of $1,138 for his care, HCA officials said after this article was initially published. But hospitals can maximize revenue by charging high trauma fees to all insurers, including those required to pay a percentage of charges, say medical billing consultants.

VCU Health charges up to $13,455 for trauma activation, according to its charge list.

Average HCA trauma activation charges are $26,000 in states where the company does business 鈥� three times higher than those of non-HCA hospitals, according to data from Hospital Pricing Specialists, a consulting firm that analyzed trauma charges in Medicare claims for KHN.

The findings are similar to those reported , early in HCA’s trauma center expansion. The Times found that Florida HCA trauma centers were charging patients and insurers tens of thousands of dollars more per case than other hospitals.

Treating trauma patients in the ER is only the beginning of the revenue stream. Intensive inpatient treatment and long patient recoveries add to the income.

“We have more Level I, Level II trauma centers today than we have ever had in the company history,” HCA’s then-CEO, Milton Johnson, told stock analysts in 2016. “That strategy in turn feeds surgical growth. That strategy in turn feeds neurosciences growth, it feeds rehab growth.” Trauma centers attract “a certain cadre of high-value patients,” Dr. Jonathan Perlin, HCA’s chief medical officer, told analysts at a 2017 conference.

Patients at HCA’s largely suburban hospitals are more likely than those at an average hospital to carry private insurance, which pays much more than Medicare and Medicaid. the company’s revenue in 2020 came from private insurers, regulatory filings show. Hospitals, in general, collect of their revenue from private insurers, according to the Department of Health and Human Services.

HCA’s trauma cases can fit the same profile. At Chippenham, in south Richmond, trauma cases are “90% blunt trauma,” according to the hospital's online job posting last year for a trauma medical director. Blunt-trauma patients are generally victims of car accidents and falls and tend to have good insurance, analysts say.

VCU and other urban hospitals, on the other hand, treat a higher share of patients with gun and knife injuries 鈥� penetrating trauma 鈥� who are more often uninsured or covered by Medicaid. About 75% of VCU’s trauma cases are classified as blunt trauma, hospital officials said.

The 90% figure is “not accurate today,” Caldwell said. “Chippenham’s current mix of trauma type is aligned with that of other trauma centers in the region, and we treat traumas ranging from motor vehicle accidents to gunshots, stabbings and other critical injuries regularly.”

鈥楾rauma Drama’ in Florida and Beyond

HCA’s growth strategy is part of a wider trend. From 2010 to 2020 the number of Level I and Level II trauma centers verified by the American College of Surgeons nationwide increased from 343 to 567.

Nowhere has HCA added trauma centers more aggressively or the fight over trauma center growth been more acrimonious than in Florida. The state’s experience over the past decade may offer a preview of what’s to come in Virginia and elsewhere.

In the thick of the controversy, 鈥� but only after the number of HCA trauma centers in the state had grown from one to 11 over more than a decade and helped spark an explosion in trauma cases, according to Florida Department of Health data.

News headlines called it “trauma drama.” Hospitals with existing centers repeatedly filed legal challenges to stop the expansion, with little effect. Florida’s governor at the time was Rick Scott, former chief executive of Columbia/HCA, a predecessor company to HCA.

After launching Level II centers across the state, HCA officials not to adopt recommending severely injured patients be treated at the highest level of trauma care in a region 鈥� Level I, if available.

HCA “kept on working, working, working, working for 10 years” to gain trauma center approvals over objections, said Mark Delegal, who helped broker the legislative settlement as a lobbyist for large safety-net hospitals. “Once they had what they wanted, they were happy to lock the door behind them.”

HCA hospitals “serve the health care needs of their communities and adjust or expand services as those needs evolve,” said Sumerford.

As HCA added trauma centers, trauma-activation billings and the number of trauma cases spiked, according to Florida Department of Health data analyzed by KHN. Statewide, inpatient trauma cases doubled to 35,102 in the decade leading up to 2020, even though the population rose by only 15%. HCA’s share of statewide trauma cases jumped from 4% to 24%, the data shows.

Charges for trauma activations, also known as trauma alerts, for HCA’s Florida hospitals averaged $26,890 for inpatients in 2019 while the same fees averaged $9,916 for non-HCA Florida hospitals, the data shows. Total average charges, including medical care, were $282,600 per case in 2019 for inpatient trauma cases at HCA hospitals, but $139,000 for non-HCA hospitals.

HCA's substantially higher charges didn't necessarily result from patients with especially severe injuries, public university research found.

Over three years ending in 2014, Florida patients with sprains, mild cuts and other non-life-threatening injuries were “significantly more likely” to be admitted under trauma alerts at HCA hospitals and other for-profit hospitals than at nonprofit hospitals, by University of South Florida economist Etienne Pracht and colleagues. HCA hospitals have admitted emergency department Medicare patients at substantially higher-than-average rates since 2011, suggesting that at other hospitals many would have been sent home, new by the Service Employees International Union found.

“What’s going on with HCA is the Wall Street model they’re following,” said Pracht, who provided KHN with additional Florida Department of Health data showing soaring trauma cases. “And Wall Street’s not happy unless you’re expanding. They’re driven by the motive to keep the stock price high.”

Lobbying and Campaign Dollars

In Virginia, health care organizations need to go through process to add something as basic as a $1 million MRI imaging machine.

But to open or upgrade a trauma center, all that’s needed is the approval of the health commissioner after a confidential qualification procedure. Chippenham did not seek or obtain Level I verification from the American College of Surgeons before getting Level I approval from the state. It is ACS-verified as a Level II center and, Caldwell said, is seeking Level I status with ACS.

Virginia requires an “extensive application” and “in-depth” site reviews by experts before a hospital gains status as a trauma center, Dr. M. Norman Oliver, the commissioner, said in an email. “Chippenham Hospital met the requirements” to become a Level I center, he said.

Nearly 80% of HCA’s Level I and Level II trauma centers have been verified by the American College of Surgeons “and the others currently are pursuing this verification,” said HCA spokesperson Sumerford.

As in other states, HCA invests heavily in Virginia in political influence. are registered with the state to advocate on HCA’s behalf. One lobbyist from December 2019 through February 2020 treating public officials to reception spreads and meals at posh Richmond restaurants such as L'Opossum and Morton’s the Steakhouse, lobbying records submitted to Virginia’s Conflict of Interest and Ethics Advisory Council show. HCA’s political action committee to state candidates last year, according to the records.

Like other hospital systems, HCA hires former paramedics for “EMS relations” or “EMS outreach” jobs. HCA’s EMS liaisons are expected to develop a “business plan, driving service line growth,” according to its employment ads.

Chippenham’s decision to start a helicopter ambulance operation last year to compete with others in transporting trauma patients surprised some public officials. HCA and its contractor had for the operation to be reimbursed by insurers when Richmond City Council members learned about it. Members “were not up to speed on this matter,” council member Kristen Larson told a May 2020 meeting of the Richmond Ambulance Authority, .

Chippenham’s air ambulance partner, private equity-owned Med-Trans, has been the subject of media reports of patients with in out-of-network bills. It’s not unusual for air ambulances to charge $30,000 or more for transporting a patient from a highway accident or just across town, according to news reports.

Last year, 85% of Med-Trans flights for Virginia patients with health insurance were in-network, said a company spokesperson. But Med-Trans is out of network for Virginia members of Aetna and UnitedHealthcare, two of the state’s biggest carriers, said spokespeople for those companies. Med-Trans is part of Anthem Blue Cross Blue Shield’s network, an Anthem spokesperson said.

HCA runs trauma centers “really well,” said Winchell, who runs the Level I trauma center at NewYork-Presbyterian Weill Cornell Medical Center.

But “there are clearly areas of oversupply” for trauma centers generally, he said.

Instead of letting a drive for profits dictate trauma center expansion, health authorities need “objective and transparent metrics” to guide the designation of trauma centers, Winchell in the Journal of the American College of Surgeons.

Free-market advocate “Adam Smith might have been a good economist,” he wrote, “but he would have been a very poor designer of trauma systems.”

KHN data editor Elizabeth Lucas contributed to this report.

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So, she was surprised when the testing company billed her insurer $250 for each swab. She feared she might receive a bill herself. And that amount is toward the low end of what some hospitals and doctors have collected.

Hospitals are charging up to $650 for a simple, molecular covid test that costs $50 or less to run, according to Medicare claims analyzed for KHN by (HPS). Charges by large health systems range from $20 to $1,419 per test, by 麻豆女优 shows. And some free-standing emergency rooms are charging more than $1,000 per test.

Authorities were saying “get tested, no one’s going to be charged, and it turns out that’s not true,” said Valfer, a professor of visual arts who lives in Pasadena, California. “Now on the back end it’s being passed onto the consumer” through high charges to insurers, she said. The insurance company passes on its higher costs to consumers in higher premiums.

As the pandemic enters its second year, no procedure has been more frequent than tests for the virus causing it. Gargantuan volume 鈥� and counting, for one type 鈥� combined with loose rules on prices have made the service a bonanza for hospitals and clinics, new data shows.

Lab companies have been booking record profits by charging $100 per test. Even in-network prices negotiated and paid by insurance companies often run much more than that and, according to one measure, have been rising on average in recent months.

Insurers and other payers “have no bargaining power in this game” because there is no price cap in some situations, said Ge Bai, an associate professor at Johns Hopkins Bloomberg School of Public Health who has studied test economics. When charges run far beyond the cost of the tests “it’s predatory,” she said. “It’s price gouging.”

The data shows that covid tests continue to generate high charges from hospitals and clinics despite by insurers, of and pushback from state regulators.

The listed charge for a basic PCR covid test at Cedars-Sinai Medical Center in Los Angeles is $480. NewYork-Presbyterian Hospital lists $440 as the gross charge as well as the cash price. Those amounts are far above the $159 national average for the diagnostic test, which predominated during the first year of the pandemic, at more than 3,000 hospitals checked by HPS.

That’s the amount billed to insurance companies, not what patients pay, Cedars spokesperson Cara Martinez said in an email.

“Patients themselves do not face any costs” for the tests, she said. “The amounts we charge [insurers] for medical care are set to cover our operating costs,” capital needs and other items, she said.

Likewise at NewYork-Presbyterian, charges not covered by insurance “are not passed along to patients,” the hospital said.

Many hospitals and labs follow the Medicare reimbursement rate, $100 for results within two days from high-volume tests. But there are outliers. Insurers oftentimes negotiate lower prices within their networks, although not for labs and testing options outside their purview.

Billing by hospitals and clinics from outside insurance company networks can be especially lucrative because the government requires insurers to pay their posted covid-test price with no limit. Regulation for out-of-network vaccine charges, by contrast, is stricter. Charges for vaccines according to federal regulations, with relatively low Medicare prices as a possible guideline.

“There’s a problem with the federal law” on test prices, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “The CARES Act requires insurers to pay the full billed charge to the provider. Unless they’ve negotiated, their hands are tied.”

But even in-network payments can be highly profitable.

Optim Medical Center in Tattnall, Georgia, part of a chain of orthopedic practices and medical centers, collects $308 per covid test from two insurers, its . Yale New Haven Hospital collects from another.

Yale New Haven’s prices resulted from existing insurer agreements addressing unspecified new procedures such as the covid test, said Patrick McCabe, senior vice president of finance for Yale New Haven Health.

“We didn’t negotiate” specifically on covid tests, he said. “We’re not trying to take advantage of a crisis here.”

Officials from Optim Medical Center did not respond to queries from KHN.

Castlight Health, which provides benefits and health care guidance to more than 60 Fortune 500 companies, analyzed for KHN the costs of 1.1 million covid tests billed to insurers from March 2020 through this February. The analysis found an average charge of $90, with less than 1% of bills passing any cost along to the patient. Since last March, the average cost has gone up from $63 to as high as $97 per test in December before declining to $89 in February, the most recent results available.

In some cases, hospitals and clinics have supplemented revenue from covid tests with extra charges that go far beyond those for a simple swab.

Warren Goldstein was surprised when Austin Emergency Center, in Texas, charged him and his wife $494 upfront for two covid tests. He was shocked when the center billed insurance $1,978 for his test, which he expected would cost $100. His insurer paid $325 for “emergency services” for him, even though there was no emergency.

“It seemed like highway robbery,” said Goldstein, a New York professor who was visiting his daughter and grandchild in Texas at the time.

Austin Emergency Center has been the subject of of high covid-test prices.

The center provides “high-quality health care emergency services” and “our charges are set at the price that we believe reflects this quality of care,” said Heather Neale, AEC’s chief operating officer. The law requires the center to examine every patient “to determine whether or not an emergency medical condition exists,” she said.

Curative, the lab company that billed $250 for Valfer’s PCR tests, said through a spokesperson that its operating costs are higher than those of other providers and that consumers will never be billed for charges insurance doesn’t cover. Valfer’s insurer paid $125 for each test, claims documents show.

Even at relatively low prices, testing companies are reaping high profits. Covid PCR tests sold for $100 apiece helped Quest Diagnostics by 49% in the first quarter of 2021 and quadruple its profits compared with the same period a year ago.

“We are expecting 鈥� to still do quite well in terms of reimbursement in the near term,” Quest CFO Mark Guinan during a recent earnings call.

Hospitals and clinics do pay tens of thousands of dollars upfront when purchasing analyzer machines, plus costs for chemical reagents, swabs and other collection materials, maintenance, and training and compensating staff members. But the more tests completed, the more cost-effective they are, said Marlene Sautter, director of laboratory services at Premier Inc., a group purchasing organization that works with 4,000 U.S. hospitals and health systems.

A of running 5,000 covid tests on Roche and Abbott analyzers 鈥� not including that initial equipment price, labor or shipping costs 鈥� came to $17 and $21 per test, respectively.

Unlike earlier in the pandemic, lab-based PCR tests no longer dominate the market. Cheaper, rapid options can now be purchased online or in stores. In mid-April, some CVS, Walmart and Walgreens stores began selling a two-pack of Abbott Laboratories’ BinaxNOW antigen test for $23.99.

Regulations require insurers to cover covid testing administered or referred by a health care provider at no cost to the patient. But exceptions are made for public health surveillance and work- or school-related testing.

Claire Lemcke, who works for a Flagstaff, Arizona, nonprofit, was tested at a mall in January and received a statement from an out-of-state lab company saying that the price was $737, that it was performed out-of-network and that she would be responsible for paying. She’s working with her insurer, which has already paid $400, to try to get it settled.

Sticker shock from covid tests has gotten bad enough that Medicare set up a hotline for insurance companies to report bad actors, and states across the country are taking action.

Free-standing emergency centers , like the one Goldstein visited, particularly exorbitant prices, propelling the Texas Association of Health Plans to in late January. The 19-page letter details how many of these operations violate state disclosure requirements, charge over $1,000 per covid test and add thousands more in facility fees associated with the visit.

These free-standing ERs are “among the worst offenders when it comes to price gouging, egregious billing, and providing unnecessary care and tests,” the letter says.

In December, the Kansas Insurance Department a lab whose cash price was listed at nearly $1,000. State legislatures in both and have introduced bills to crack down on price gouging since the pandemic began.

"If these astronomical costs charged by unscrupulous providers are borne by the health plans and insurers without recompense, consumers will ultimately pay more for their health care as health insurance costs will rise,” Justin McFarland, Kansas Insurance Department’s general counsel, wrote in a Dec. 16 letter.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

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