No quería que sus próximas vacaciones se arruinaran por una faringitis estreptocócica, por eso, después de una semana, decidió hacerse ver.

Kasdan visitó a su médica de atención primaria, la doctora Roya Fathollahi, en Manhattan Specialty Care, cerca de Park Avenue South, y no muy lejos de Tony Gramercy Park.

La visita fue rápida. Le hicieron un hisopado de garganta, le sacaron sangre y se fue del consultorio con una receta para antibióticos.

Se sintió mejor pronto, e hizo el viaje sin problemas.

Entonces… llegó la factura.

Paciente: Alexa Kasdan, de 40 años, consultora de políticas públicas en la ciudad de Nueva York, con seguro de Blue Cross Blue Shield de Minnesota a través del empleador de su pareja.

Factura total: $28,395.50 por un hisopado de garganta fuera de la red. Su aseguradora pagó con un cheque por $25,865.24.

Proveedor de servicios: doctora Roya Fathollahi, Manhattan Specialty Care.

Servicio médico: pruebas de laboratorio para buscar posibles bacterias y virus que podrían estar relacionados con la tos y el dolor de garganta de Kasdan.

Qué le pasó: cuando Kasdan regresó del viaje al extranjero, dijo que había “varios mensajes en mi teléfono y un correo electrónico del departamento de facturación del consultorio de la doctora Fathollahi”.

La noticia fue que su aseguradora le estaba enviando un cheque a su familia, por más de $ 25,000, para cubrir algunas pruebas de laboratorio fuera de la red. La factura total era de $28,395.50, pero el consultorio del médico dijo que renunciaría a su parte de la cuenta: $2,530.26.

“Pensé que era un error”, dijo. “Pensé que tal vez querían decir $250. Era imposible de entender en qué universo posible iría a un médico para un cultivo de faringitis estreptocócica y algunos antibióticos y terminaría con una factura de $25,000”.

El consultorio del médico le aseguró a Kasdan por teléfono y por correo electrónico que las pruebas y los cargos eran perfectamente normales. Le enviaron un mensajero a su casa para recoger el cheque.

¿Cómo podría un hisopado de garganta costar tanto? Tres razones.

Primero, el médico envió el hisopado de garganta para una sofisticada variedad de pruebas de ADN en busca de virus y bacterias que pudieran explicar los síntomas del resfriado de Kasdan.

El , profesor de medicina familiar en la Facultad de Medicina de la Universidad de Georgetown, dijo que este escrutinio era completamente innecesario. Hay pruebas rápidas y baratas para estreptococos e influenza.

“En mis 20 años como médico, nunca he ordenado ninguna de estas pruebas, y mucho menos he visto a ninguno de mis colegas, estudiantes y otros médicos, ordenar algo así en un ámbito ambulatorio”, dijo. “No tengo idea por qué los pidieron”.

Las pruebas podrían tener sentido para un paciente en una unidad de cuidados intensivos, o en un caso difícil de neumonía, agregó Mishori. Los de la influenza son potencialmente útiles, ya que hay medicamentos que pueden ayudar, pero hay una prueba rápida y barata que podría haberse usado.

“Hay alrededor de 250 virus que causan los síntomas del resfriado común, e incluso si supiera que había virus A versus virus B, no habría diferencia porque de todos modos no hay tratamiento”, dijo.

(Los resultados de laboratorio de Kasdan no revelaron el virus particular que fue el culpable del resfriado. Y fueron negativos).

La segunda razón detrás del alto precio es que el médico envió el hisopado para que lo analizara un laboratorio fuera de la red. Los laboratorios dentro de la red liquidan las tarifas contractuales con las aseguradoras. Sin embargo, los que están fuera de la red pueden establecer sus propios precios, y en este caso el laboratorio se decidió por precios de lista que son 20 veces más altos que el promedio de otros laboratorios en el mismo código postal.

En este caso, si el médico hubiera enviado el hisopado a LabCorp, el proveedor de la red de Kasdan, le habría facturado a su compañía de seguros alrededor de $653 por “todas las pruebas ordenadas, o un equivalente”, dijo LabCorp a NPR.

La tercera razón de la alta factura puede ser la conexión entre el laboratorio y el médico de Kasdan. La factura de Kasdan muestra que el servicio de laboratorio fue proporcionado por Manhattan Gastroenterology, que tiene el mismo número de teléfono y ubicaciones que el consultorio de su médica.

Manhattan Gastroenterology está registrada como una corporación profesional en el estado de Nueva York, lo que significa que es propiedad de médicos. Puede ser la compañía matriz de Manhattan Specialty Care, pero eso no está claro en sus presentaciones ante el estado.

Fathollahi, la médica de Manhattan Specialty Care, no respondió a las solicitudes de comentarios. Tampoco el doctor Shawn Khodadadian, que figura en los registros estatales como el CEO de Manhattan Gastroenterology.

El patólogo que figura en la “explicación de beneficios” (EOB) de la aseguradora es el doctor Calvin L. Strand. Figura en los registros estatales como director de laboratorio de Manhattan Gastroenterology, así como en Brookhaven Gastroenterology en East Patchogue, Nueva York. También tratamos de contactarlo para que hiciera comentarios.

A pesar que Kasdan no quedó atrapada por esta factura, prácticas como ésta aumentan el costo de la atención médica. Las aseguradoras basan las primas en sus gastos, y cuanto más aumentan, más tienen que pagar los participantes.

“Puede que no estés pagando nada por este reclamo en particular”, dijo , abogada que se especializa en facturación médica en el Forbes Law Group en Overland Park, Kansas, quien investigó este caso para NPR. “Pero, en general, si los reclamos y los costos del grupo aumentan, todos los empleados y cónyuges del plan de salud pueden eventualmente pagar el costo de esto”.

Marting dijo que éste es un problema común para las aseguradoras. La mayoría del procesamiento de reclamos está completamente automatizado, dijo. “Nunca hay ojos humanos que miren la factura y decidan si se paga o no”.

Kasdan pagó su copago habitual de $25 por la visita al consultorio y una tarifa de $9.61 a LabCorp por un conjunto separado de pruebas de laboratorio.

Resolución: “Dejé muy claro [al consultorio del médico] que no estaba contenta con esto”, dijo Kasdan. De hecho, les dijo que reportaría al médico a la Oficina de Conducta Médica Profesional del Estado de Nueva York. Luego, contactó a “Bill of the Month”, el proyecto conjunto de NPR y Kaiser Health News.

Después que un periodista comenzó a hacer preguntas sobre la factura, Blue Cross Blue Shield de Minnesota suspendió el pago del cheque que emitió y ahora está investigando.

Jim McManus, director de relaciones públicas de BCBS, dijo que la compañía tiene un proceso para señalar cargos excesivos. “Desafortunadamente, esas revisiones necesarias no ocurrieron en este caso”, escribió en un correo electrónico.

La conclusión: a menudo surgen facturas sorpresa cuando un médico u hospital dentro de la red involucra a otro proveedor que no está en la red de proveedores del seguro del paciente, sin el consentimiento del paciente. Generalmente es casi imposible que un paciente detecte cuándo está ocurriendo eso.

Los pacientes pueden tratar de protegerse de las facturas sorpresa pidiendo detalles en las citas con el médico.

“Siempre pregunto dónde están enviando mis pruebas o dónde están enviando mis placas [como rayos X], así puedo asegurarme que esté dentro de la red con mi compañía de seguros”, dijo el abogado Marting.

También pueden investigar por qué se ordena una prueba:

“Está bien preguntarle a tu médico:” ¿Por qué está ordenando estas pruebas y cómo le ayudarán a elaborar un plan de tratamiento? “, dijo Mishori, de Georgetown. “Creo que es importante que los pacientes estén capacitados y hagan estas preguntas, en lugar de enfrentar pruebas y tratamientos innecesarios y también, en este caso, una facturación escandalosa”.

Si estás sentado en la mesa de examen pensando: “No preguntaré. … ¿Cuánto podría ser?”, la respuesta podría ser mucho.

El estado de Nueva York tiene una ley para proteger a los pacientes de cuentas sorpresa. La ley exige que los consultorios médicos adviertan a los pacientes con anticipación que están utilizando un proveedor fuera de la red y que los pacientes pueden ser responsables de los cargos excesivos. Si un paciente no da su consentimiento para la participación de un médico fuera de la red, entonces se lo debe proteger de esa factura. Pero no impide que los proveedores fuera de la red envíen una factura o cobren a una aseguradora.

Kasdan dijo que en su cita no le dijeron que el hisopado de garganta se estaba enviando fuera de la red, aunque es posible que uno de los muchos documentos que firmó incluyera una advertencia general de que algunos servicios podrían no estar dentro de la red.

Las personas que sospechan que una factura es el resultado de una violación de la ley pueden informarlo a las autoridades estatales. En este caso, el que investiga las quejas es el .

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The 40-year-old public policy consultant from Brooklyn, N.Y., didn’t want her upcoming vacation trip ruined by strep throat. So, after it had lingered for more than a week, she decided to get it checked out.

Kasdan visited her primary care physician, Dr. Roya Fathollahi, at Manhattan Specialty Care just off Park Avenue South, and not far from tony Gramercy Park.

The visit was quick. Kasdan got her throat swabbed, gave a tube of blood and was sent out the door with a prescription for antibiotics.

She soon felt better and the trip went off without a hitch.

Then the bill came.

Patient: Alexa Kasdan, 40, a public policy consultant in New York City, insured by Blue Cross and Blue Shield of Minnesota through her partner’s employer.

Total Bill: $28,395.50 for an out-of-network throat swab. Her insurer cut a check for $25,865.24.

Service Provider: Dr. Roya Fathollahi, Manhattan Specialty Care.

Medical Service: Lab tests to look at potential bacteria and viruses that could be related to Kasdan’s cough and sore throat.

What Gives: When Kasdan got back from the overseas trip, she said, there were “several messages on my phone, and I have an email from the billing department at Dr. Fathollahi’s office.”

The news was her insurance company was mailing her family a check ― for more than $25,000 ― to cover some out-of-network lab tests. The actual bill was $28,395.50, but the doctor’s office said it would waive her portion of the bill: $2,530.26.

“I thought it was a mistake,” she said. “I thought maybe they meant $250. I couldn’t fathom in what universe I would go to a doctor for a strep throat culture and some antibiotics and I would end up with a $25,000 bill.”

The doctor’s office kept assuring Kasdan by phone and by email that the tests and charges were perfectly normal. The office sent a courier to her house to pick up the check.

How could a throat swab possibly cost that much? Let us count three reasons.

First, the doctor sent Kasdan’s throat swab for a sophisticated smorgasbord of DNA tests looking for viruses and bacteria that might explain Kasdan’s cold symptoms.

, a professor of family medicine at the Georgetown University School of Medicine, said such scrutiny was entirely unnecessary. There are cheap rapid tests for strep and influenza.

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

The tests might conceivably make sense for a patient in the intensive care unit, or with a difficult case of pneumonia, Mishori said. The ones for influenza are potentially useful, since there are medicines that can help, but there’s a cheap rapid test that could have been used instead.

“There are about 250 viruses that cause the symptoms for the common cold, and even if you did know that there was virus A versus virus B, it would make no difference because there’s no treatment anyway,” she said.

(Kasdan’s lab results didn’t reveal the particular virus that was to blame for the cold. The results were all negative.)

The second reason behind the high price is that the doctor sent the throat swab to an out-of-network lab for analysis. In-network labs settle on contract rates with insurers. But out-of-network labs can set their own prices for tests, and in this case the lab settled on list prices that are 20 times higher than average for other labs in the same ZIP code.

In this case, if the doctor had sent the throat swab off to LabCorp ― Kasdan’s in-network provider ― it would have billed her insurance company about $653 for “all the ordered tests, or an equivalent,” LabCorp told NPR.

The third reason for the high bill may be the connection between the lab and Kasdan’s doctor. Kasdan’s bill shows that the lab service was provided by Manhattan Gastroenterology, which has the same phone number and locations as her doctor’s office.

Manhattan Gastroenterology is registered as a professional corporation with the state of New York, which means it is owned by doctors. It may be the parent company of Manhattan Specialty Care, but that is not clear in its filings with the state.

Fathollahi, the Manhattan Specialty Care physician, didn’t respond to requests for comment. Neither did Dr. Shawn Khodadadian, listed in state records as the CEO of Manhattan Gastroenterology.

The pathologist listed on the insurance company’s “explanation of benefits” is Dr. Calvin L. Strand. He is listed in state records as the laboratory director at Manhattan Gastroenterology, as well as at Brookhaven Gastroenterology in East Patchogue, N.Y. We tried to reach him for comment, as well.

Even though Kasdan wasn’t stuck with this bill, practices like this run up the cost of medical care. Insurance companies base premiums on their expenses, and the more those rise the more participants have to pay.

“She may not be paying anything on this particular claim,” said , a lawyer who specializes in medical billing at the Forbes Law Group in Overland Park, Kan., who looked into this case for NPR. “But, overall, if the group’s claims and costs rise, all the employees and spouses paying into the health plan may eventually be paying for the cost of this.”

Marting said this is a common problem for insurance companies. Most claims processing is completely automated, she said. “There’s never a human set of eyes that look at the bill and decide whether or not it gets paid.”

Kasdan did pay her usual $25 copay for the office visit, and a $9.61 fee to LabCorp for a separate set of lab tests.

Resolution: “I made it very clear [to the doctor’s office] that I was unhappy about it,” Kasdan said. In fact, she told them she would report the doctor to the New York State Office of Professional Medical Conduct. Next, she reached out to “Bill of the Month,” a joint project of NPR and Kaiser Health News.

After a reporter started asking questions about the bill, BCBS of Minnesota stopped payment on the check it issued and is now investigating.

Jim McManus, director of public relations for Blue Cross and Blue Shield of Minnesota, said the company has a process to flag excessive charges. “Unfortunately, those necessary reviews did not happen in this case,” he wrote in an email.

The Takeaway: Surprise bills often arise when an in-network doctor or hospital involves another provider who isn’t in the patient’s insurance network, without the patient’s consent. But it is often nearly impossible for a patient to detect when that is occurring.

Patients can try to protect themselves from surprise bills by asking for details at their doctor’s appointments.

“I always ask where they’re sending my labs or where they’re sending my images [like X-rays], so I can make sure that’s in-network with my insurance company,” attorney Marting said.

They can also probe why a test is being ordered:

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

If you’re sitting on the exam table thinking, “I won’t ask. … How much could it be?” The answer could be a lot.

New York state has a law to protect patients from surprise bills. The law requires doctors’ offices to warn patients in advance that they are using an out-of-network provider and that patients may be responsible for excess charges. If a patient doesn’t consent to the involvement of an out-of-network doctor, then they must be financially held harmless for the bill. But it doesn’t prevent the out-of-network providers from sending a bill or collecting from an insurer.

Kasdan said she was not told that the throat swab was being sent out of network at the time of her appointment, though it’s possible one of the many papers she signed included a broad caveat that some services might not be in-network.

People who suspect a bill is the result of a violation of law can report that to state authorities. In this case, investigates complaints.

You can contact NPR science correspondent Richard Harris at rharris@npr.org.

Bill of the Month is a crowdsourced investigation by Kaiser Health News and that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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Constance Creasey is one of the thousands of people who find themselves caught up by this peculiar feature of the .

Creasey started kidney dialysis about 12 years ago after her kidneys failed. That meant going to a dialysis center three times a week, for three hours per session. (A typical patient undergoes three to five hours of dialysis per session).

“The first three years of dialysis was hard. I walked around with this dark cloud. I didn’t want to live, I really didn’t,” she says.

Being dependent on these blood-cleansing machines was physically and emotionally draining. But she stuck it out for 11 years. Medicare pays for dialysis, even for people under the age of 65. It also pays for kidney transplants for people with end-stage renal disease.

“It’s probably about 30 percent of people who find themselves in a troublesome spot at this 36-month mark,” he says.

Some people end up trying to stretch out their drug supplies by not taking them as often as they need to, he says. “We see that a lot.”

But this isn’t like skipping a pain pill and bearing the consequences. People lose their transplanted kidneys through organ rejection if they don’t take their medicine religiously.

Rita Alloway, a clinical pharmacist at the University of Cincinnati, says she also encounters this false economy. “If we were telling them to take four pills twice a day, they may start taking three pills twice a day without telling us, to extend their coverage that they had for the prescriptions they had,” she says.

If people tell her that they can’t afford it, she can help them get the medications for free, Alloway says. But sometimes people are too proud to admit their financial distress, she said.

And instead of spending $15,000 a year on these anti-rejection drugs, people go back onto dialysis, which costs $90,000 a year or more. And that’s taxpayers’ money, provided with no time limit.

Kevin Longino, CEO of the , says it’s not just affecting the people who have transplants, but those who are on the long list waiting their turn for an organ to become available.

“The tragedy is you have so many people on the wait list already, and to have someone unnecessarily have rejection because they can’t afford the drugs and to have to go back into the system — it’s just a difficult thing to explain, why we’re allowing that to happen.”

Longino says insurance companies are making the problem even worse. Some have reclassified anti-rejection drugs as “specialty drugs,” and they now require patients to pay for a percentage of the cost, rather than a more traditional fixed copayment.

Longino encountered that himself after he had a kidney transplant about a dozen years ago. He says his costs went from $150 a month to $950 a month when his insurance company made that cost-sharing shift.

He, Alloway and Cooper have been trying to persuade Congress to pass to fix this problem. Rep. Michael Burgess, R-Texas, and Rep. Ron Kind, D-Wis., have introduced bills more than once, but they have not moved through Congress. Burgess’ office says they plan to try again next year.

Lawmakers are concerned about the costs. Severe kidney a staggering $30 billion a year, and there’s no official cost-benefit analysis showing whether covering transplant drugs for everybody would save money overall.

“The Medicare [savings] in maintaining this drug coverage is better than putting people on dialysis,” Cooper says. “To me this is a no-brainer. I just cannot understand why we haven’t got to the point where we say Medicare coverage for life for immunosuppressive drugs because people will benefit and money will be saved.”

For Constance Creasey, this is not an abstract conversation.

“Those pills are my life right now,” she says. “I’m trying not to worry, but it’s hard.”

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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