COVID-19 Tests: How surprise billing affects patients across the country

Anna Adler

Approximately one million Americans a day receive a COVID-19 test, often with the expectation the test will be free.1 However, many have found coverage is not guaranteed through private insurance, resulting in surprise bills ranging from $50 to as much as $2,000.2 Despite efforts to increase price transparency and ensure access, patients are often unclear what these surprise bills are for and where they come from. Fortunately, there are steps you can take to protect yourself.

What is surprise billing for COVID-19 tests?

Surprise billing is defined as when a patient unknowingly receives care from a healthcare provider who is outside of their insurance coverage so the patient is charged full price for the services.3 Surprise billing had attracted much criticism in the US prior to the COVID-19 pandemic. In 2020, one third of insured people ages 18-64 said that they or someone in their family received an unexpected medical bill in the last two years for a service they thought was covered by insurance.4 Congress has attempted to address this issue; the No Surprises Act was included in a bill that was signed in 2021, barring health insurance companies from charging patients with surprise medical bills for seeking treatment with emergency services and certain out-of-network providers.

The Families First and Coronavirus Relief Act requires that testing for COVID-19 be free for patients, as well as any associated doctor’s visit, emergency room, or urgent care.5 This law applies to all types of health insurance, including Medicaid, Medicare, and private insurance.5 Insurers must pay for all out-of-network testing, regardless of the type of test (PCR, antigen, serological, at-home) or the cost of the test.5 Additionally, U.S. Department of Health and Human Services established the Provider Relief Fund to cover the costs associated with treating and testing individuals who do not have insurance. As a result, providers may apply for reimbursement for any COVID-19 testing costs for uninsured patients. Despite the law, however, research shows that 2.4% of COVID-19 tests billed to health insurance are being charged to patients, whether it is for the full amount or a portion of the cost of the test.2 The New York Times reports that surprise bills are more likely to come from COVID-19 tests that are administered in a hospital or private provider setting.2

An executive order issued by President Biden in January 2021 removed additional barriers to COVID-19 testing by clarifying that neither private nor public health insurance can deny coverage of a test even if individuals who are asymptomatic or do not have a known exposure to COVID-19.6,7 If a healthcare provider deems a test is medically necessary, insurance must cover the costs. In December 2021, President Biden announced an executive order that required private insurance to also reimburse beneficiaries for at-home COVID-19 tests, in an effort to protect against additional spread of the Omicron COVID variant.8 At the same time, President Biden increased the availability of free take-home tests at thousands of locations across the country.

Questions have been raised about who must pay COVID-19 tests that are required by workers who are not vaccinated and do not want to lose their jobs. The Occupational Services and Health Administration mandate had required employers with 100 workers or more to ensure that all employees are vaccinated or submit to regular testing.9 However, a judge has blocked that mandate as of November 8, 2021.10 The President’s executive order does not include routine testing for work requirements, therefore private health insurance would have no obligation to cover these tests.

Where do surprise bills for COVID-19 tests come from?

An investigation of surprise COVID-19 testing bills from The New York Times reveals loopholes protect insurance providers. For example, insurers asserted that patients would not be billed for COVID-19 tests if the appointments were “coded” (categorized) as testing for the virus. However, if any other codes, such as an accompanying doctor’s appointment, were applied to the charge, patients would receive bills that they would have to pay. Moreover, bills that have been submitted to the Times investigation also suggest that insurance companies were illegally applying copays and deductibles to COVID-19 tests.11

The New York Times also reported that patients sometimes unknowingly were tested at an out-of-network healthcare provider. In some cases the healthcare provider who performed the test was in-network, but the patients were charged because the lab that analyzed the patient’s sample was not.9 One patient even reported that although they thought their sample was just being tested for COVID-19, they received a bill for $1,000 because the lab also tested for Legionnaires’ disease, herpes and enterovirus based on the same sample.2 Patients have also reported other surprise bills for their COVID-19 tests, such as an “after-hours fee.”

How individuals can protect themselves from surprise billing

Before individuals get tested for COVID-19, they should make sure they understand the different types of tests, such as PCR, antigen, serological, and over-the-counter tests.

There are a few tips for individuals to protect themselves from getting a surprise bill on their COVID-19 test:

#1 Key questions to ask your healthcare provider: 12,13

  • Do you use an outside laboratory? If yes, is it in my network?
  • What are you going to be billing me for?

Key questions to ask your health insurance company:

  • What is my coverage for COVID testing?
  • Do you cover rapid tests, PCR tests, and antibody tests?
  • Do you cover tests whether they are done with an in-network or an out of network provider or laboratory?
  • Do you cover at-home testing kits that are not ordered by a medical professional?

#2 Get tested at a local public testing site. Using state, county, or local public health department testing is a good way to avoid fees.12 Click here to find community-based COVID-19 testing.

#3 If you are not insured, talk to the health professional providers about payment options for COVID-19 tests and treatment.

#4 Ensure that the healthcare provider codes the visit as a COVID-19 test so that the insurance company knows not to charge co-pays.

#5 If you receive a surprise bill for COVID-19, contact your health insurance company and obtain an Explanation of Benefits (EOB) to help you clarify any extra charges on a bill. If it looks incorrect, they can call the insurer to discuss the errors and if you’re sure you’re right, be persistent.

Although Congress has made attempts to fix problems and close loopholes surrounding charges for COVID-19 tests, individuals across the country still receive surprise bills for services that they thought were covered. This article is an effort to protect patients by helping them understand the rules and regulations that determine what health insurance can and cannot charge you for.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

The National Center for Health Research is a nonprofit, nonpartisan research, education and advocacy organization that analyzes and explains the latest medical research and speaks out on policies and programs. We do not accept funding from pharmaceutical companies or medical device manufacturers. Find out how you can support us here.

References

  1. CDC Covid Data tracker. Centers for Disease Control and Prevention. https://covid.cdc.gov/covid-data-tracker/#cases_tests7day.
  2. Kliff S. Coronavirus tests are supposed to be free. the surprise bills come anyway. https://www.nytimes.com/. https://www.nytimes.com/2020/09/09/upshot/coronavirus-surprise-test-fees.html. Published September 9, 2020.
  3. News Division. HHS announces rule to protect consumers from surprise medical bills. HHS.gov. https://www.hhs.gov/about/news/2021/07/01/hhs-announces-rule-to-protect-consumers-from-surprise-medical-bills.html. Published July 1, 2021.
  4. Kearney AF, Lopes L. Data note: Public worries about and experience with surprise medical bills. https://www.kff.org. https://www.kff.org/health-costs/poll-finding/data-note-public-worries-about-and-experience-with-surprise-medical-bills/. Published February 28, 2020.
  5. Adler L, Young CL. The laws governing covid-19 test payment and how to improve them. Brookings.Edu. https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2020/07/13/the-laws-governing-covid-19-test-payment-and-how-to-improve-them/. Published March 12, 2021.
  6. Press Release. Biden administration strengthens requirements that plans and issuers cover covid-19 diagnostic testing without cost sharing and ensures providers are reimbursed for administering COVID-19 vaccines to uninsured. CMS.gov. https://www.cms.gov/newsroom/press-releases/biden-administration-strengthens-requirements-plans-and-issuers-cover-covid-19-diagnostic-testing. Published February 26, 2021.
  7. Press Release. Executive Order on Establishing the COVID-⁠19 Pandemic Testing Board and Ensuring a Sustainable Public Health Workforce for COVID-⁠19 and Other Biological White House Briefing Room. https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/21/executive-order-establishing-the-covid-19-pandemic-testing-board-and-ensuring-a-sustainable-public-health-workforce-for-covid-19-and-other-biological-threats/. Published January 20, 2021.
  8. Press Release. President Biden Announces New Actions to Protect Americans Against the Delta and Omicron Variants as We Battle COVID-⁠19 this https://www.whitehouse.gov/briefing-room/statements-releases/2021/12/02/fact-sheet-president-biden-announces-new-actions-to-protect-americans-against-the-delta-and-omicron-variants-as-we-battle-covid-19-this-winter/ Published December 2, 2021.
  9. Kliff S. How to avoid a surprise Bill for your coronavirus test. The New York Times. https://www.nytimes.com/2021/08/18/upshot/coronavirus-test-bill-cost.html. Published August 18, 2021.
  10. Rosenberg E., Marlow AE. Federal appeals court halts Biden administration’s vaccine requirement, delivering policy a major blow. The Washington Post. https://www.washingtonpost.com/business/2021/11/12/biden-vaccine-mandate-court-ruling/. Published November 12, 2021.
  11. Kliff S. Coronavirus tests are supposed to be free. the surprise bills come anyway. The New York Times. https://www.nytimes.com/2020/09/09/upshot/coronavirus-surprise-test-fees.html. Published September 9, 2020.
  12. Cummings D. Tips to protect yourself from surprise medical bills. MASSPIRG. https://masspirg.org/blogs/blog/map/tips-protect-yourself-surprise-medical-bills. Published June 18, 2021.
  13. Kliff S. How to Avoid a Surprise Bill for Your Coronavirus Test. The New York Times. https://www.nytimes.com/2021/08/18/upshot/coronavirus-test-bill-cost.html. Published September 9, 2020.