Carmen Aiken of Chicago made an appointment for an annual physical exam in July 2023, planning to get checked out and have blood work done.
The appointment was at a family medicine practice run by University of Illinois Health. Aiken said the doctor recommended they undergo a Pap smear and testing for sexually transmitted infections. Aiken, who works for a nonprofit and uses the pronoun they, was also encouraged to get the HPV vaccine.
They’d tested positive for HPV in 2019 and eventually cleared the virus but hadn’t gotten the vaccine to prevent future infections.
“Sounds like a good idea,” Aiken, 37, recalled telling the doctor.
They also needed some lab work — part of routine monitoring for one prescription. After being examined, Aiken said, they were directed to a different part of the office building to get blood drawn and receive the first dose of the vaccine before leaving.
Then came the bill for what Aiken thought would be a free yearly exam: $1,430.
The medical procedure
The services at Aiken’s appointment included a pelvic exam, a vaccination and blood work to check, among other things, glucose levels and liver function.
A yearly physical typically includes a variety of services, many that insurers are required to cover under the federal Affordable Care Act, such as reviewing the patient’s health history, screening for high cholesterol and performing a Pap smear to check the cervix for signs of cancer.
Updating immunizations is also a common and typically covered service that’s a part of checkups. The vaccine for HPV — the human papillomavirus — provides protection against an infection that can cause several types of cancer. Federal health officials recommend being immunized for HPV at 11 or 12, though the vaccine also can be administered later in life.
The final bill
It was $1,430.13.
That broke down to $1,223.22 for lab services and pathology, plus $206.91 for “professional services,” which included a charge for a 40-minute “High Mdm” outpatient visit — indicating a high level of “medical decision-making” — as well as charges for immunization administration and vaccines.
A hospital price tag for blood work
The billing issue for Aiken is that not all services that might be provided as part of a yearly physical necessarily will be covered by insurers as preventive care.
Someone who needs blood work for a specific medical concern — as Aiken did, for medication monitoring — could be required to pay part of the bill. That’s true even if the blood work is performed during a checkup alongside preventive services.
Some health insurers pay for standard blood work as part of a preventive visit. But that’s not always the case.
Aiken had purchased a health insurance plan on the federal marketplace and thought the visit would be covered at no cost.
When the bill came for more than $1,400, Aiken thought, “How did this happen?”
They said they called their insurer, BlueCross BlueShield of Illinois, and then, after an initial inquiry went nowhere, filed an appeal for the $1,223.22 amount owed for lab services, thinking: “Surely, this is a misunderstanding.”
But the insurer sided with UI Health’s position that the blood work wasn’t preventive. In a letter denying Aiken’s appeal, BlueCross BlueShield of Illinois said that “the labs were billed correctly as diagnostic.”
The insurer decided that Aiken was on the hook for 50% of the cost of outpatient labs performed in a hospital setting.
Dave Van de Walle, a spokesperson for BlueCross BlueShield of Illinois, wouldn’t discuss Aiken’s bill.
Francesca Sacco, a UI Health spokesperson, said Aiken scheduled the appointment for “medication monitoring and to obtain a vaccine.
“Medication monitoring is not considered a wellness benefit under the Affordable Care Act,” she said.
Sacco also said Aiken’s labs were sent for processing to University of Illinois Hospital, more than a mile from the family medicine practice.
That left Aiken owing more. Hospitals typically charge much more than doctors’ offices or independent commercial labs for the same tests.
The distinction between a preventive visit and a diagnostic one is important for billing purposes: It dictates who’s on the hook for the bill. A preventive visit generally comes at no cost to patients. But a visit for an ongoing medical issue is usually classified as diagnostic, leaving the patient subject to copays and deductibles — or even charged for two separate appointments.
Patients might not notice a difference in the exam room. Much of that nuance is determined by the medical provider and captured on the bill.
There’s still confusion about such billing matters 15 years after the ACA’s preventive services protections took effect, according to Sabrina Corlette, a founder and co-director of Georgetown University’s Center on Health Insurance Reforms.
“This is an outrageous bill for what should have been routine care,” Corlette said. “People just don’t have this kind of money lying around.”
The resolution
After the insurer denied the billing appeal, Aiken “fell down a hole into despair about it for a while. And then someone really wise was, like, ‘You can pay it, and then just stop thinking about it.’”
So that’s what Aiken did: “I put it on my credit card.”
Sacco said UI Health works with insurers to resolve cost-sharing disputes, “however, it is the insurance company’s sole discretion whether a service is fully covered or subject to cost-sharing. In this case, the insurer determined that cost-sharing would be applicable to a specific portion of the services provided to the patient. Based on this determination, the patient was billed accordingly by UI Health.”
The experience had a lasting impact on Aiken, who said that last year they walked out of an urgent-care visit after a doctor recommended a Pap smear — fearing that would result in another big bill.
The takeaway
Delaying or avoiding care can lead to worse outcomes, which is why lawmakers tried to ensure that patients generally would pay nothing for preventive services like immunizations under the ACA.
Yearly checkups are a key element of preventive care.
For instance, most adults who never got the HPV vaccine don’t know they’re still eligible, so it’s critical to inform them of their options, said Dr. Verda Hicks, a gynecologic oncologist in Kansas City, Missouri. The vaccine offers protection against nine types of HPV and against HPV-related cancers in men, so the federal Centers for Disease Control and Prevention recommends that boys get the shot, too.
“Get vaccinated,” Hicks said, pointing out the difference it makes for HPV. “We just do not have the same tools for many other cancers.”
But some insurance companies won’t cover the cost of the vaccine for some older patients — and the same services might be subject to different cost-sharing rules depending on whether they are conducted for prevention versus diagnosis.
Also, prices can vary depending on where you go for care and where the tests are performed. If you need a blood test, ask that your doctor send the requisition to a commercial, in-network lab. People might not realize that labs drawn at a clinic could be sent to a hospital for testing, opening them to higher costs.
There has been a push in Congress to eliminate this price variation through “site-neutral” payment policies under which, regardless of location, the price for routine care would be reimbursed at the same amount.
“Site-neutral reforms could potentially have significantly reduced Carmen’s expenses,” said Christine Monahan, an assistant research professor at Georgetown’s Center on Health Insurance Reforms.
Potentially upending the current systemm a case before the Supreme Court could eliminate the requirement that insurers cover preventive services like vaccines and annual screenings at no cost to patients. If the justices — who heard oral arguments on that on April 21 — side with the plaintiffs, Corlette said, “Then, we all potentially lose access to free, high-value preventive care. And that would be a real shame.”
Samantha Liss and Lauren Sausser are reporters for KFF Health News.