< The colonoscopies were free but the 'surgical trays' came with $600 price tags

JUANA SUMMERS, HOST:

All right. It is time for our Bill Of The Month. Dr. Elisabeth Rosenthal is senior contributing editor with our partner, KFF Health News. Welcome back, Doctor.

ELISABETH ROSENTHAL: Oh, another year, more stories.

SUMMERS: Another year, more bills. So tell us, who are we meeting this month?

ROSENTHAL: This month we're speaking to Chantal Panozzo. She lives outside Chicago. She and her husband got routine colonoscopies last year to screen for colon cancer. The law says preventive care services like this are supposed to be fully covered without any cost to the patient. But Chantal and her husband ended up with identical his and her bills for some really downright bizarre charges.

SUMMERS: OK. I want to hear more about that. Reporter Zach Dyer takes it from here.

ZACH DYER: Chantal Panozzo got quite a birthday present from her primary care doctor when she turned 45 last year.

CHANTAL PANOZZO: And he was like, happy birthday. Congratulations. You're that age. So here's your referral.

DYER: For a colonoscopy. Screenings like this are supposed to help catch colon cancer or other gut issues that can come with getting older. Chantal says, in a weird way, she was looking forward to it. Her husband had gotten his colonoscopy earlier that year too.

PANOZZO: It was supposedly free, and we don't get a lot of free things for our premiums. So we thought, yep, for sure.

DYER: Everything went fine. But about a month later, Chantal got a bill from the doctor's office - $250.

PANOZZO: No. This can't be happening, not again.

DYER: Chantal couldn't believe it. They had just spent months contesting her husband's $250 bill, which had come from the same doctor. And now she was about to start all over again.

PANOZZO: I thought, what is going on? Why am I getting billed for things that are supposed to be free?

DYER: And Chantal couldn't even figure out what she was supposed to pay for.

PANOZZO: So on the bill itself, it was code A4550.

DYER: She called her insurer. She says the agent on the phone told her it was a code for surgical trays.

PANOZZO: So then I called the billing department of the provider, and she actually told me something different.

DYER: Chantal says they told her, yes, the code was technically for surgical supplies, but that's not how they were using it. Instead, Chantal says they were using this code as a stand-in for something they called a use cost for the doctor's office.

PANOZZO: No one knew code A4550, and no one can decode it. So it just made me think all the more, yes, I'm going to appeal this because my provider and my insurer can't even agree with this charge is for.

DYER: So Chantal got to work. She studied the law, reviewed the insurance benefit handbook, called the state insurance authority, drafted and redrafted appeal letters. It took months. Finally, her appeals worked. The insurer said she and her husband weren't expected to pay anything.

PANOZZO: I did almost quit, you know. But I just thought, this isn't about 250, this isn't about 250 times two. These little bills matter. And I think those of us who can should try to do it for the sake of everyone else.

DYER: But Chantal says she couldn't even savor the victory. In this case, the win was not having to pay a bill she shouldn't have had to pay in the first place.

SUMMERS: That was Zach Dyer with our partner KF Health News reporting. And we're back now with Dr. Elisabeth Rosenthal. Dr. Rosenthal, I mean, this was supposed to be a preventative service, so how did Chantal end up with a bill?

ROSENTHAL: You know, I love patients like Chantal. Under the Affordable Care Act, health insurance companies are responsible to make sure preventive care for things like a mammogram or a colonoscopy are available at no cost to the patient. What the law doesn't specify is how doctor's offices bill for that care or what billing codes they use. Medical providers have pretty broad leeway, and sometimes odd charges can show up on your bill for care you expect to be fully covered.

SUMMERS: I mean, as we heard, Chantal was really diligent. She filed appeal after appeal, tracked this all down. But it raises the question, is anyone out there actually policing this kind of medical billing behavior?

ROSENTHAL: Well, one expert we spoke to said insurance companies should crack down on doctors' offices and other health providers they work with. But, you know, to them, a charge of $250 here and there is peanuts - not worth the manpower and trouble to contest it. Chantal's insurer, Blue Cross and Blue Shield of Illinois, declined to comment on the case.

SUMMERS: Right. And the law we've been talking about, the Affordable Care Act, it was designed to encourage people to seek out care that keeps them healthy. So square this all for us.

ROSENTHAL: Medical prices are a big worry for many Americans. Chantal's case shows a loophole in the Affordable Care Act. Certain preventive care should be free to patients, but it leaves a lot of wiggle room on how it's billed, and providers can try to bill for add-ons.

SUMMERS: Right. So what can patients do?

ROSENTHAL: Well, unfortunately, patients like Chantal have to be the police themselves. Wait to get the explanation of benefits from your insurer before you pay the bill. If you see something suspicious, especially for a procedure you thought should be free, speak up and contest the charge. I mean, free means free for preventive care.

SUMMERS: And is there anything else that we should note about Chantal's bill specifically?

ROSENTHAL: The doctor's office, the Illinois Gastroenterology Group, declined to comment. A staffer there referred us to the GI Alliance, which manages the practice. And here's the punch line. The GI Alliance is a private-equity-backed network with 800 gastroenterologists working in 15 states. They didn't respond to our request for comment.

SUMMERS: That's Dr. Elisabeth Rosenthal, senior contributing editor with our partner, KFF Health News. Dr. Rosenthal, thank you.

ROSENTHAL: Thanks for having me.

SUMMERS: And if you have a confusing or outrageous medical bill that you want us to review, please go to NPR's Shots blog and tell us all about it.

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