The doctor wasn’t sure what to make of the line on her son’s medical bill.
After his routine appointment in Norfolk, she’d received the statement in the mail, with one $15 charge labeled “PPE,” referring to personal protective equipment.
Familiar with the murkiness of medical billing, she figured it was an error. Her son hadn’t received any equipment during the office visit.
But Bayview Physicians Group said it wasn’t a mistake. The bill correctly included a fee for the extra equipment worn by medical staff to protect against COVID-19.
The doctor, who wished to remain anonymous due to professional concerns, shared her son’s bill with The Virginian-Pilot out of concern. It appears the $15 was covered by insurance or otherwise written off in her case, but she was worried for others.
During the pandemic, when many are already in dire financial straits, should providers be able to charge for doing what’s needed to protect both parties? Are insurers footing the bill or are patients left to pick up the tab?
The answer, as so often with the money side of the medical establishment, is complicated.
The coronavirus pandemic hit doctors’ offices hard. At the same time that regular services were reduced, overhead expenses have spiked.
An economic impact survey by the American Medical Association last summer found medical practices had seen their revenues drop by about a third on average, coupled with an average increase in spending on personal protective equipment of 57%.
In the fall, the AMA created a new billing code that allows providers to be compensated for additional supplies and staff time to do safety protocols to care for patients in a public health emergency.
That’s what led Bayview Physicians Group in Hampton Roads to start adding the $15 fee, said Gina Gremminger, the group’s marketing director.
She emphasized that it is never supposed to reach a patient’s wallet. Whether or not patients see the fee as a line item on their bill, the intention is for insurance to pick up the tab. Bayview does not plan to charge uninsured patients and would not pursue the fees from those whose insurance denied it, she said.
“As a medical group, we use the designated code to help track pandemic related expenses we are required to report,” Gremminger said in an email. “More and more insurance companies are recognizing the additional financial burdens that physician medical groups are experiencing while being front line providers of care to patients during this unprecedented pandemic and provide reimbursement to help offset some of the costs.”
The problem is that insurers are not required to pay under the new code.
Dr. Hao Feng, a dermatologist at UConn Health who has written about the ethics of charging such fees during the COVID-19 crisis, said a lot of insurance companies have chosen not to.
“Many physicians have been going down this road, but a lot of companies are still denying it.”
The Center for Medicare & Medicaid Services, for example, is not paying under the new code. A spokesperson said Medicare considers the costs under the code to already be bundled into separately payable services.
The concept of billing patients for staff PPE actually started in the dental world, where it is more common, Feng said. The American Dental Association has pushed insurers to cover small fees related to the added expense.
An Anthem insurance spokesperson said the company paid its in-network dentists an additional $10 per member to cover additional equipment expenses last summer, consistent with the dental association’s guidance. For health care providers, though, Anthem considers compensation for supplies already included in provider agreements and therefore not eligible for separate reimbursement.
Aetna did not respond to an inquiry by press time.
Feng said it makes sense that smaller practices, including dentists, would try to offset costs of the pandemic.
The larger health systems in Hampton Roads — Sentara Healthcare, Bon Secours and Chesapeake Regional Healthcare — all said they are not charging for PPE.
Patient bills from around the country examined by The New York Times, however, had a host of COVID-related fees, from $60 for PPE tacked onto an expensive ambulance bill to $900 for masks and a meal delivery.
Some state attorneys general have gotten involved.
In a letter to Maryland’s dental association last summer, that state’s chief consumer protection division head said the office had gotten complaints about the increased fees that officials believed may violate the Consumer Protection Act’s prohibition against unfair or deceptive trade practices. A press release from the office soon afterward alerted consumers to the charges.
Regulators in Connecticut and New York have also warned that state and federal laws don’t allow in-network providers to tack on new fees, the Times reported.
Virginia Attorney General Mark Herring’s office has received a handful of complaints about the charges during the pandemic, according to spokesperson Charlotte Gomer.
“As Virginia continues to cope with the unprecedented COVID pandemic, it’s so important that Virginians act kindly towards one another and make decisions that are in the best interest of keeping themselves, their families and communities safe,” she wrote.
Gomer encouraged Virginians to report concerns to the state’s Consumer Protection Section, but did not respond to followup questions about Herring’s stance on the matter.
In his article on the ethics, Feng raised the legal concern of whether providers can add a cost when contracts negotiated with insurers are already established.
“Even in those cases where it is legal, charging uninsured or out-of-network patients may make medically necessary care less affordable and therefore would be an assault on distributive justice, causing an increase in cost and thereby reducing access to health care, especially for lower socioeconomic patients,” he wrote. “Furthermore, it is unethical to only bill the surcharge to uninsured patients or seek surcharge reimbursement only from those insured.”
It’s a tricky situation, he said in an interview, especially considering how important it is to keep medical practices’ lights on for their communities. He hopes insurers will help.
“It’s still a struggle in a lot of practices … but at the same time its even more critical we maintain access for patients,” he said. “We need to do our best to stay within legal boundaries to provide care necessary while advocating for our practices. So the burden isn’t unduly on one or the other but shared.”
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