Even before a novel virus swept around the world, Anna Davis Abel wore a mask to protect herself from getting sick.
The 25-year-old writer lives with lupus, a chronic autoimmune disease that makes her more susceptible to infection. Davis Abel's doctor cleared her to travel to a literary conference in San Antonio in early March. She developed a sore throat and low-grade fever several days after arriving home in Morgantown, W.Va.
Consulting a nurse on the phone, Davis Abel was told to manage her symptoms at home. But her symptoms only worsened, so she made an appointment with her primary care doctor.
"At that point, I was, like, taking shot glasses of Sudafed," she said.
Given the spread of the coronavirus and a chronic condition that left her vulnerable to a more serious case of COVID-19, she was concerned she had been infected. To find out, her doctor first ordered tests to evaluate whether Davis Abel's symptoms were caused by some other respiratory disease. According to the doctor's notes in her medical record, "we needed to rule out all other viral possibilities before being eligible for the COVID-19 test."
"Unfortunately at this time, COVID-19 testing is very limited and is not widely available to most patients," it continued.
Davis Abel tested positive for influenza B.
Then the bill came.
The patient: Anna Davis Abel is a 25-year-old graduate student studying creative writing at West Virginia University in Morgantown. She is insured through an Aetna plan the university offers.
Total amount billed: WVU Medicine charged Davis Abel $2,121 for the visit and testing, according to records. Aetna initially paid $1,584.54 for these services. Abel was responsible for the copay, the remaining amount of her deductible and coinsurance of 20%. In total, she owed $536.46.
The providers: Davis Abel visited the WVU Healthcare University Town Centre clinic for her primary care appointment. A laboratory within the WVU health system processed her testing for respiratory disease. Both sites were in-network for her plan.
Medical services: A specimen collected from the back of Davis Abel's nose and throat was tested for more than a dozen respiratory diseases.
What gives: Congress has taken action to make COVID-19 testing more affordable for consumers with health insurance.
The Families First Coronavirus Response Act requires private insurers to pay for certain services and items related to testing at no cost to the patient. A second piece of legislation, known as the CARES Act, expanded the number of tests and services insurers must cover at no cost. The latter law also requires health plans to reimburse out-of-network providers for their services. However, there are gaps in these federal protections that may expose patients to unexpected medical bills.
The guidelines state that insurers are required to cover an appointment without cost sharing only if the doctor orders or administers a COVID-19 test. Even if the patient shows symptoms and receives other care related to the novel virus, without a test, the patient may be on the hook for the cost of the visit, said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.
"They're getting a battery of other tests," said Corlette. "But because there's not enough [COVID-19] tests, they can't get this protection."
A national shortage of COVID-19 tests complicates a patient's ability to qualify for the federal safeguard. Despite efforts by the federal government and the private sector, some resources needed to increase testing remain scarce, said Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists.
This reality means some medical providers, like Davis Abel's doctor, must rule out other respiratory diseases before ordering a COVID-19 test, leaving some patients with a difficult choice. Do they seek medical attention and risk a high medical bill? Or do they forgo care altogether?
A second hole in these federal protections may leave patients holding the bill for their COVID-19 test. The law prohibits insurers from charging patients for testing, but it does not block medical providers from doing so. If an insurer does not cover the total amount charged by a provider, the patient may get balance-billed, or slapped with a surprise charge.
Guidance from the federal Department of Health and Human Services says that that should not happen because almost any patient can be considered at risk for COVID-19 right now, but it's unclear if or how that will be enforced.
Davis Abel's appointment was on March 11, making her ineligible for the protections offered by the federal laws. By then, however, Aetna had pledged to cover COVID-19 testing without cost sharing. The hospital system then sent Davis Abel a bill for the remaining amount.
WVU Medicine declined to comment on the case.
Consumers may find protection from these bills through a requirement attached to federal relief funding for medical providers. Health care facilities that receive any of the $100 billion from the CARES Act Provider Relief Fund are not allowed to balance-bill patients for COVID-19 treatment.
Resolution: Aetna retroactively covered Davis Abel's bill from the hospital after calls from reporters. In a statement, the insurer said it is waiving claims after receiving information from her provider that the services were related to COVID-19 testing.
It also said that Davis Abel represents a "unique" case and that it is not aware of another member submitting claims for services they needed to obtain a COVID-19 test. The insurer said it would waive additional testing related to the coronavirus if the provider deemed those services necessary.
Before Aetna took action, two strangers read Davis Abel's story on Twitter and sent her the full amount for the bill. She used the donations to help pay for a medical bill from a previous procedure.
Nearly 10 days after her appointment, Davis Abel received a drive-through COVID-19 test offered by the same clinic. Her primary care doctor, who ordered the test, said in an email to Davis Abel that new data suggested patients could fall ill with the coronavirus and the flu at the same time.
Davis Abel's fever and coughing had not subsided. Eight days after the test, she received her result. Negative for COVID-19. She did not pay for the test.
The takeaway: Experts recommend that insured patients educate themselves about their health care plan. Seek care at an in-network provider whenever possible. Call the insurer to find out exactly what COVID-19 care it covers. Several insurance companies have pledged to waive cost sharing for treatment.
Uninsured consumers may be able to get a free COVID-19 test several ways. One way is to visit an outpatient testing area at a facility that received relief funding — the law bars the provider from balance-billing patients for care related to the coronavirus.
Another option is through Medicaid. States may now use the government health insurance program for the poor and disabled to cover the cost of testing uninsured residents who qualify.
A third way consumers could receive a free COVID-19 test is through the National Disaster Medical System. That network of health care providers — generally activated in response to an emergency — treats patients and then charges the federal government for their services. However, it may be difficult to find a provider who participates in the program.
"The problem right now is the supply of them," Sara Collins, vice president for health care coverage and access at the Commonwealth Fund, said about COVID-19 tests, "but once that changes, people need to be confident that they're not going to be stuck with a big bill."
Dan Weissmann, host of the podcast An Arm and a Leg, reported the audio version of this story.
Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
RACHEL MARTIN, HOST:
One of the worries associated with COVID-19 is the thought of getting stuck with a huge medical bill. Congress passed laws in March to protect patients, and some insurance companies have pledged to waive copays and deductibles. But as you might guess, there are loopholes. So for our Bill of the Month segment, NPR and Kaiser Health News decided to look at one of those loopholes. Dan Weissman has the story.
DAN WEISSMAN, BYLINE: If you were going to pick somebody to fight a weird medical bill, you could do worse than Anna Davis Abel of West Virginia. She's a grad student, flexible job and no kids. She's got some time to haggle with insurance. And she's got a special qualification. After college, Anna worked in a doctor's office where she haggled with insurance companies for a living. And if you were to pick somebody who really needed a coronavirus test last month, she'd be on your short list there, too. She had just been on a plane, and she has lupus. That's a chronic disorder that means any potentially serious illness poses a special threat. And she had classic COVID symptoms - rising fever and a dry cough that kept getting worse.
ANNA DAVIS ABEL: I had been, like, mainlining Mucinex. I was like, why am I so sweaty? I feel like a man, like, no offense.
WEISSMAN: Anna's doctor said to come in but also said there were hardly any coronavirus tests in the state of West Virginia. To get one for Anna, they would need to...
ABEL: Prove, you know, beyond a reasonable doubt that it was nothing more common and more viral.
WEISSMAN: Anna tested positive for flu. But a week later, her doc was still worried and sent her in for a test. The nasal swab was no fun. Anna documented it on Snapchat.
(SOUNDBITE OF VIDEO)
ABEL: Oh, my God, that woman took my soul out of my head with that Q-tip. She actually grabbed the back of my head like we were lovers, but instead of kissing me, she was impaling my brain.
WEISSMAN: That wasn't even the worst of Anna's problems that day. Later, she got a statement from her insurance company, Aetna, about that first test.
ABEL: And I was like, you know, this COVID stuff is supposed to be covered. I wonder how that looks. Lo and behold, my insurance company was saying that I owed $536 and I think 47 cents.
WEISSMAN: Actually 46 cents. That was her share, the notice said, of a $2,000 charge for that test.
ABEL: At first, I was like, oh, this is just - you know, they just messed up here. LOL, guys.
WEISSMAN: But when Anna called Aetna and called and called, they said this wasn't a mistake. The billing record didn't include a COVID-specific diagnosis code.
ABEL: And even though my doctor had put in written words, like, this is a part of COVID-19 testing in our state, the person on the other end of the line was not able or allowed - and, I mean, one of them actually said, I'm not allowed to look at that.
WEISSMAN: Anna posted her medical record and the insurance statement to Twitter, which got results - many retweets and a reporter got in touch with Anna and Aetna. That got the company's attention.
ABEL: Within 20 minutes of the reporter emailing me back saying that he had spoken to them, I got a call.
WEISSMAN: And they've since paid her bill in full. Aetna wouldn't go on tape with us. In an emailed response, the company said the information that Ms. Abel's health care provider shared with us initially did not code the service as related to COVID-19. But it's not clear that appropriate codes existed when Anna got her tests. Aetna's statement called Anna's case unique, meaning - and I asked - that no other Aetna customer has had to pay for a test they got in order to get a COVID test. OK.
Meanwhile, legal protections for consumers are a work in progress. Sabrina Corlette runs the Center on Health Insurance Reforms at Georgetown University. She says when Anna got that first test, no national law obligated insurers to cover it. Later in March, Congress passed laws mandating full coverage for COVID-related testing. Would those laws have protected Anna?
SABRINA CORLETTE: Well, this is where I'm going to get super lawyerly on you and your audience is going to just want to, like, shoot me with daggers.
WEISSMAN: Short version - no. The current law only kicks in if a visit includes an order for a coronavirus test even if a test isn't immediately available.
CORLETTE: I would expect most doctors don't know that if they don't actually order a test at the moment of the first visit that their patient could be exposed to these out-of-pocket costs.
WEISSMAN: So, bam, if you get seen for anything that could be COVID, maybe get your doctor to order a coronavirus test whether a test is available or not. Otherwise there could be a loophole and a bill with your name on it. For NPR News, I'm Dan Weissman. Transcript provided by NPR, Copyright NPR.