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Brian Lehrer: It's The Brian Lehrer Show on WNYC. Good morning again, everyone. Coronavirus tests are supposed to be free. The idea is that the only way to make sure that the public health system can contain the virus is to make sure the tests are accessible to everybody and the people shouldn't need to worry about being straddled with debt for doing their part in preventing the spread of COVID. Some people are finding themselves with surprise bills.

One woman in New York, for example, got tested after seeing an ad for free tests and later received a bill for more than $2,700. Some 2.4% of coronavirus tests leave the patient on the hook for part of the cost. When you think about the number of tests given in America, that could mean hundreds of thousands of Americans getting billed. This is according to reporting for my next guest, New York Times investigative reporter Sarah Kliff. Hey, Sarah, welcome back to WNYC.

Sarah Kliff: Thanks for having me back.

Brian: By way of context, unfortunately, it seems like we're all too familiar with stories about people receiving these huge surprise bills for routine medical procedures, an $80,000 bill for an appendectomy for example. Given what we know about the cost of medical care in America, should we be surprised that people are getting these bills for COVID tests?

Sarah: I'll say yes and no. No, because this is just the way our health care system works. As you were mentioning, Brian, Americans have become really familiar with big surprise medical bills. It's something I wrote about. Before coronavirus, it's something I continue to write about afterwards. The reason though I think this should be somewhat surprising is that insurance companies, Congress, the Trump administration, everyone tried to write special rules for coronavirus, for testing a treatment to say, "Okay, it's a pandemic. This should not cost Americans. They should not be worried about getting care related to coronavirus."

What we're starting to learn over the past few months is that those special rules that tried to carve out this one area of the health care system is different. The one area where Americans aren't financially vulnerable, they're not slotting so neatly into a health care system where the first instinct is really just bill, bill, bill patients. It's an area where the rules are supposed to be different, but patients are quickly finding some of the places where those rules fall short.

Brian: Congress passed the Families First Coronavirus Response Act back in March. That legislation prevents insurers from charging co-payments or applying deductibles to COVID tests and other "items and services furnished" in visits to the doctor. Where's the gray area that allows insurers and providers to bill patients for these tests?

Sarah: Actually, that section you read is really perfect for talking about this. It seems pretty clear. It seems black and white. For the coronavirus test and for the doctor visit to get the coronavirus test, insurance companies should not be charging co-payments or deductibles. They should be covering that in full. The place where it gets tricky is that question about other services furnished.

For example, let's say a woman goes to the hospital to have a baby and gets the coronavirus test at the hospital. It's been pretty clearly decided that that does not qualify for these rules just because a coronavirus test is provided. The gray area is like let's say someone goes to the hospital and they get an X-ray and they get a flu test and they got all these other things because they're feeling sick.

Doctors are trying to decide, "We'll figure out what's wrong with this patient." That's become a gray area of insurance billing. Does that kind of visit qualify for these protections or not? It's tricky. Sometimes patients don't even know what tests are being run on and they think it's just a coronavirus test. Some other tests are tapped on and those tests fall in a gray area where the Trump administration hasn't really released guidance saying, "Okay, here's the related services. This is what counts on the list."

Brian: Listeners, help us report this story. Have you received a surprise bill after getting tested for COVID-19? Where did it happen? How much was it? How did your insurance company explained the charges or your provider? Did you contest the charge in any way? Tweet @BrianLehrer or give us a call now at 646-435-7280 for Sarah Kliff, who I imagine is going to stay on this story as an investigative health reporter for The New York Times. 646-435-7280. Sarah, if insurers are just flat-out not following the rules, how can they be held accountable?

Sarah: Well, I think part of that is by putting some [unintelligible 00:05:06] what's happening. That's what I tried to do in my latest story by looking at cases where it seemed like insurance companies weren't following the rules. Part of it is good reporting like myself and others are doing on this topic. Part of it could be more clarity from the Trump administration.

One of the things that always happens here in Washington where I work is Congress writes the rules, but then it's on the executive branch to fill in the gaps and write regulations that spell out in really minute detail what insurance companies have to cover. I've talked to some folks who'd be like, "Clear guidance could help." If patients want to help, like you said, Brian, they can call and tell us about their experiences.

I'm continuing to collect bills for coronavirus treatment and testing for a project I'm doing for The New York Times. We have about 325 bills right now. I would love to have more. If anyone has received a bill related to coronavirus, surprising or not, bigger, little, please, please, please send it to me at nytimes.com/costofcare. It's a really simple form. It helps us figure out if insurance companies are following the rules in the first place.

Brian: What's that email address again in case it went too quickly for people?

Sarah: Nytimes.com/costofcare.

Brian: Oh, that's a website.

Sarah: It's a website, yes. You can submit your bill. It's a really easy form we created.

Brian: Okay, cool. There's something that you just said that made me wonder if there's a larger pattern here. I don't know if you've reported on this. When you said that maybe the Trump administration, which enacted these rules, free COVID tests, aren't being aggressive enough in making sure that they're followed. There was a story on Morning Edition today about another pronouncement from the President, which is that you're not going to get evicted for COVID-related financial problems that are preventing you from paying your rent.

Officially, this comes from the Centers for Disease Control but at the direction of the President. They're not reaching out according to the story. A lot of landlords don't know, a lot of court systems don't know when this wind up in some kind of landlord-tenant court. I wonder if there's a pattern of the President making these big pronouncements on COVID things that are actually good, but then there isn't the follow-through to get the details out there. I don't know if that's a pattern of any kind, but it strikes me that I heard this from you just now on COVID tests and from NPR on the eviction protections this morning.

Sarah: I'm focused on the health care area. I can say you certainly see it there. You see the trickle-down effect is if you don't have clear guidance, it's that often individuals who either don't have the means to fight this or don't even know something wrong is happening. Individuals are the ones who end up dealing with the effects of not having clear guidance and clear regulation. I can definitely tell you, Brian, it's happening in the health care space.

I will say, to be somewhat sympathetic to the insurance companies, these are a whole new set of rules that were thrown at them in the middle of a pandemic. One insurance company told me they're having to go in and hand-recode each claim they get related to coronavirus. Their system just wasn't set up to handle these claims and handle new rules that showed up in the middle of the year. It is a challenging situation. Everything about this pandemic is challenging, but I do think the lack of clarity to follow executive orders and follow legislation certainly layers another challenge on top of an already challenging situation.

Brian: Sometimes it seems with this administration that they like to say things, but not necessarily do the spadework of doing things. Alex in Williamsburg, you're on WNYC. Hi, Alex. Thanks for calling in.

Alex: Hi, thanks so much for taking my call. I am a long-time listener and first-time caller.

Brian: Good. You're on.

Alex: I got tested-- Thank you so much. I got tested for COVID at a CityMD with my partner and we both asked the intake person that there would be no charge. They assured us that our insurance wouldn't bill us. We have two different insurances and we both got bills for over $300.

Brian: What did you do?

Alex: [chuckles]

Brian: What did you do?

Alex: We got them yesterday, so we don't know what to do. Any advice, I appreciate it.

Brian: Good timing for this segment for Alex in Williamsburg. Sarah, can you help her?

Sarah: Yes. Well, Alex, I'd love to take a look at your bills and maybe we can connect after this show. I would say reach out to your insurance company. If this was a coronavirus test, they really should-- it'd be a very rare exception when they should not be covering it. I would reach out to your insurance company first to understand why you're receiving these bills. Hopefully, that yields a little bit of clarity. Again, I'd be happy to take a look at them for you because I'm trying to understand what's going on in situations exactly like yours.

Alex: Wonderful. Thank you so much.

Brian: All right, so what was that New York Times website again where Alex could submit her bill?

Sarah: Nytimes.com/costofcare.

Brian: Cool. Well, I'm going to go right to another caller. Jules in the West Village, you're on WNYC with Sarah Kliff from The New York Times. Hi, Jules.

Jules: Hi. Thank you. Prior to COVID, I and others who've had experiences with hospitals and doctors double billing, essentially sending bills to the insurance company and billing the patient, not even waiting for the insurance company to respond. I'm wondering if something similar might be going on here.

Sarah: I haven't come across that. In the bills I've read so far, I haven't run into that particular situation yet, but I agree with you. It is one that happens in our health care system and I think it just speaks to the fragmentation. That's so different about the American health care system compared to other ones in developed nations where there's this split between insurance pay sum and patients' pay sum. You do see hospitals engaging that kind of behavior or sending bills out to both parties. I haven't seen it yet, but it wouldn't surprise me if that turns out with coronavirus as well.

Brian: Some of the contexts of this surprises me. Like Reed Abelson, your colleague at The Times, reported last week that the health insurance industry has recorded big profits and benefited from the pandemic. That really surprises me because you would think that people have more medical expenses that they're submitting, that they're covered for. It would be bad for the insurance companies. Are you familiar with this at all?

Sarah: Yes. I think, actually, what happened is we see a lot of evidence. We know a lot of hospitals had to shut down elective care in March and April, particularly in somewhere like New York City where you really needed that surge capacity and just didn't want more people being out in the world possibly getting infected. You really saw just a huge, huge, huge decline and care delivered in March, April, and May.

It's been coming back over the past few months. When there's fewer people in the hospital, particularly getting some of those surgeries that tend to be expensive, knee replacements, hip replacements, things like that, that's all money insurance companies are not spending, even though they continue to take in the same premiums. We're going to how that shakes out.

There's some rules in the Affordable Care Act that would require some refunds to patients or people paying for these health insurance plans eventually if there is a suit surplus, but it seems pretty clear that the coronavirus pandemic, because of all this care that got canceled, has really been a boon to insurance companies when you just focus on their earnings.

Brian: Wow, so that's the financial side of this. I guess on the personal side, we get to your article that came out on Friday. Missed vaccines, Skipped Colonoscopies: Preventive Care Plummets was the headline. There are health consequences from that that you're reporting?

Sarah: Yes. One of the things we just saw some new data on last week is that you really saw this decline of all sorts of preventive care, including colonoscopies, mammograms, a lot of really crucial childhood vaccines like HPV and measles. They just really nosedive by about 50% to 70% at the height of the pandemic. I think, really, it's going to take us a few years to understand the health consequences of that.

We should be on the lookout for measles outbreaks in the next year because there are fewer kids getting vaccinated. Health researchers, they're going to be looking at, is there an uptick in colon cancer diagnoses or breast cancer diagnoses because of all this missed care? I think we're actually going to learn a lot about this preventive care that most of us usually get how much it matters by studying this unfortunate experiment that we're living through, where a lot of preventive care that usually happen didn't happen.

Brian: Here's another caller. Sachin in Oakland, California. Hi, Sachin. You're on WNYC.

Sachin: Hi, Brian. Hello, how are you doing? Way back in March, I came down with a heavy fever and my insurance is Blue Cross Blue Shield. At that time, there's so much confusion that I ended up going to a Kaiser Permanente ER and getting a checkup and test. It's something from a chest and from a radiology perspective. I started getting some bills. I spoke to Blue Cross Blue Shield and they said that they'll take care of it. It shouldn't happen, but I get a bill last week of $327. It's strange that after having spoken a couple of times, this is yet happening.

Brian: Sarah, what's going on in that case? You have enough clues?

Sarah: I have a few ideas again. I think I have a bit of a broken record, but I'd love to take a look at them if you submit them. It sounds like there might be some network issues going on where the health insurance companies-- Like you're saying, you went to a Kaiser facility, which is usually it's on network and that it might've not have been in-network with your health insurance.

You do see some insurance companies, again, trying to write special rules for coronavirus saying, "If it was coronavirus, we're going to waive the network stuff. We're going to cover it in full." I don't know the exact rules your plan has written about this, but that might be why they are saying, "We're going to cover this. Don't worry about it. It's a special situation."

Again, if that is the case, it's a good example of insurance companies trying to write these special rules saying they're going to take care of it, but patients still experiencing bills because this is something new to insurance companies. They're setting up new systems and the systems don't always work perfectly as they're getting stood up in real-time. That's my best guess of what might be going on here.

Brian: Sachin, good luck with that, but it sounds like the in-plan, out-of-plan rules still apply.

Sarah: They do, they do. This is an area where right before coronavirus, there was a real big push in Congress to fix some of that, to get rid of surprise billing, those bills that happen when you go to an in-network hospital, but one of the doctors that sees you without a network. Congress are pretty close to passing something in December, but they didn't get it across the finish line.

That means that patients are still vulnerable to the possibility of going somewhere where it seems like it's a network, but it turns out the anesthesiologist or the lab your coronavirus-- This is something I've seen a lot actually where you go to an in-network facility for a test, but then it turns out the lab that your doctor sends your test to is out-of-network. You can end up with some pretty significant bills that way.

Brian: What if you're uninsured? We've been talking so much about what the insurance companies are doing.

Sarah: If you are uninsured, Congress and the Trump administration has set up a fund to cover the bills of testing a treatment of coronavirus patients. As one of my colleagues, [unintelligible 00:17:52] has reported, that program has also shown some weaknesses. She documented cases of some uninsured patients receiving pretty significant bills for their coronavirus care.

I've heard through my projects from patients who are uninsured and receiving significant bills for their coronavirus testing. What seems to have happened is that the administration set up this fund that hospitals and doctors could apply to. If they treated someone who's uninsured, they could send the bills to this government fund and get reimbursed. The problem is we have a really different health system.

Not everybody knows about the fund or knows how to submit or they might just find it a lot easier to do what they normally do, which is bill the patient versus learn how to submit to this new government program. It seems like a bit of a mixed bag. Some uninsured folks are getting pre-test at city sites and it's working fine. Others are getting significant bills for their coronavirus tests and that's a real problem.

Brian: Michael in Brooklyn, you're on WNYC. Hi, Michael.

Michael: Hi, how are you?

Brian: Okay, you also have a story about a notice from your insurance company?

Michael: Yes. Your guest just made point was that the urgent care place that my son and I went to get COVID tests, we got the blood serum test, as well as the active COVID test. That was in-plan, but the lab was not in-plan. Anthem just sent me the possibility that I could owe the lab over $1,700 for each of us. About $3,400 is what the lab is looking for. We just got a letter from the lab that says, "Well, your insurance company covered it." The insurance company, by the way, paid almost a thousand dollars for each bus for these two tests.

It's not as though the lab can get money. Now, the lab is coming to us looking at what they call sub-abrogation, where they're looking to see if there's another insurance company. This is a test as a result of an accident. Is it part of workmen's comp or is there another insurance company that they can chase for this money which-- They haven't said that we don't owe anything. They're just looking right now to see if there's another insurance company, which stunned me, just the fact that the lab could charge $2,700 at the end of the day for each of us.

Brian: I think that's pretty much standard procedure where they will go looking for who or the third-party payers might be on anything. How about the price of that coronavirus test, Sarah? Is that unusual?

Sarah: It's unusual but not unheard of. I have been doing a bunch of reporting on the actual cost of the coronavirus test, which I'd say a regular cost is about $100. That's what Medicare or the program that covers that the elderly pays. That's what some large labs are charging. You do see some labs taking advantage of the fact that the United States does not regulate health prices in any way and charging upwards of-- The most expensive individual coronavirus test I've seen are about $2,500 or so.

Again, that's 25 times what Medicare is paying. I think this is certainly pushing the outer bounds of what you're seeing labs testing, but it's not totally unheard of. The rules around this are really, really messy. I'd be happy to follow up with this listener about it. There are rules around out-of-network billing. Congress did try to generate some special rules for out-of-network coronavirus tests and require insurance companies to pay the cash price that the lab lists on their websites.

Sometimes labs are not listing their cash prices or they're very hard to find. It doesn't seem like there's a lot of oversight happening in this space. This is something I'm thinking about doing a little more reporting on because you do see a lot of these scenarios coming up of-- and people going to in-network providers for coronavirus test, having a set of in-network labs, and ending up in this exact situation that you're describing. Again, I'd be happy to take a look at those bills and give you my best guess and what kind of protection you have. It's something that's coming up a lot. It's a real problem when the coronavirus tests are in hundreds of dollars.

Brian: Last thing before you go. I see your latest story is about how hard it was for you to get testing for your two-year-old after an outbreak at his daycare, really?

Sarah: Yes. This is another-- Usually, I get a lot of my stories from reading medical bills or talking to experts. This was a case where my two-year-old son was actually a great source. Another student in a daycare tested positive and he was growing up, so we wanted to get him tested as well. It turns out in Washington, DC where I live, all these public sites are only age six and up. It was a whole ordeal trying to find a site that would test a toddler.

After I finally did find him a test site, I put on my reporter had and started looking into it and found a lot of parents are running into this exact issue that a lot of test sites have age minimums. New York City is not among them. I will mention it because we have a lot of readers there in New York City. Public testing sites will test children of all ages. There are a lot of large cities where I live, Washington, Miami, and Dallas, San Francisco that set age minimums. That made parents scrambling to find testing for their children. I kind of stumbled into what ended up being a pretty interesting story.

Brian: What's the advice for other people who might find themselves in that situation as more people go back to their daycare providers this fall?

Sarah: I think maybe doing some research ahead of time could be helpful. It's not something I thought to look up, but it's certainly easier to research coronavirus testing resources when your child is in childcare versus when you're trying to take care of them and do that research test. In my situation, we really wanted to go to a drive-thru test because we thought it would be a family lower risk to the providers. One of the things I wish I had done in a few pretty moments, which are very hard for working parents to find right now, is a little bit of research about where there was a drive-thru site that I could go to if my son needed a coronavirus test.

Brian: Okay, good tip. I'm going to invite you, our listeners, to get your typing fingers or your analog pens and pencils ready because Sarah is going to give that web address one more time if you want to submit your bills to contribute to her reporting or to get an answer for yourself on what the heck is going on here. Just to be super clear, is this only for bills related to COVID tests or other kinds of COVID bills as well?

Sarah: Any kind of medical bills related to coronavirus testing or treatment, hospital. I talked to some people who have to go to therapy afterwards, occupational therapy, mental health therapy. Really, any sort of medical bills related to coronavirus testing or treatment, I would love to see them. The address where they can be submitted is nytimes.com/costofcare. A huge thank you to anyone who sent me one. I really appreciate it.

Brian: Sarah Kliff, investigative health reporter for The New York Times. Sarah, thanks as always.

Sarah: Of course. Thanks for having me.

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