In her late 20s and attending college in Texas, Elizabeth Moreno suffered from debilitating back pain caused by a spinal abnormality. "I just could not live with the pain," she says. "I couldn't get dressed by myself, I couldn't walk across my house, let alone to class, and nothing, no drug that had been prescribed to me, even dulled the pain."
Moreno says she also tried chiropractic medicine and acupuncture, but they didn't make the pain go away. Finally, a doctor at the student health center referred her to an orthopedic specialist who performed tests and concluded a disk was blocking nerves down her legs and needed to be removed. Moreno's father, a retired Ohio doctor who had seen many failed back surgeries over his career, agreed it was the best course.
In late 2015, Moreno had the operation in Houston, which she described as "a complete success." She gave it little thought when the surgical office asked her to leave a urine sample for a drug test.
Then the bill came.
Patient: Elizabeth Moreno, then 28, a student at Texas State University in San Marcos.
Total bill: $17,850 for a urine test in January 2016
Service provider: Sunset Labs LLC of Houston
Medical treatment: Moreno had a disk removed from her back in December 2015. Her surgeon prescribed an opioid painkiller, hydrocodone. At a follow-up office visit in mid-January 2016, the staff asked her to leave a urine sample, which she figured was routine. In March 2017, the lab sent her a bill for $17,850 for testing her urine for a slew of drugs, including cocaine, methadone, anti-anxiety drugs and several other drugs she had never heard of.
What gives: Urine drug testing has exploded over the past decade amid alarm over rising opioid overdose deaths. Many doctors who prescribe the pills rely on the urine tests to help reduce drug abuse and keep patients with chronic pain safe. Yet the tests have become a cash cow for a burgeoning testing industry, and critics charge that unneeded and often expensive ones are sometimes ordered for profit rather than patient care. Doctors can decide whether to test patients who take opioids for short periods, such as after an operation. Moreno's surgeon would not discuss her urine test — why he ordered it and why the sample was tested for so many substances.
Three experts contacted by Kaiser Health News questioned the need for such extensive testing and were shocked to hear of the lab's prices. They said these tests rarely cost more than $200, and typically much less, depending on the complexity and the technology used. Some doctors' offices use a simple cup test, which can detect several classes of drugs on the spot and could be purchased for about $10. Bills can climb higher when labs run tests to detect the quantity of specific drugs and bill for each one, as the lab did here.
The experts said the lab's prices for individual tests were excessive, such as charging $1,700 to check for amphetamines or $425 to identify phencyclidine, an illegal hallucinogenic drug also known as PCP. They also criticized a charge of $850 for two tests to verify that her urine sample had not been adulterated or tampered with.
Moreno's insurer, Blue Cross and Blue Shield of Texas, refused to pay any of the bill, arguing that the lab was out of network and thus not covered. Had it chipped in, it would have covered the service at $100.92, according to an explanation of benefits the insurance company sent to Moreno.
Sunset Labs says its list prices were "in line" with its competitors in the area. It also said doctors treating pain agree extensive urine testing is "the best course of action" and that a lab "is not in the position" to question tests ordered by a doctor.
Resolution: Fearing damage to his daughter's credit rating, Moreno's father, Dr. Paul Davis, paid the lab $5,000 to settle the bill in April 2017. A retired doctor, he also has filed a formal complaint about the bill with the Texas attorney general's office, accusing the lab of "price gouging of staggering proportions." The lab's attorney said he was not aware of the complaint. A Texas attorney general's spokesperson confirmed to KHN that the office had received complaints about the lab but declined further comment.
The takeaway: When a physician asks for a urine or blood sample, always ask what it's for. Insist that it be sent to a lab in your insurance network.
Source: Texas attorney general complaint; interviews
This is the debut of a monthly feature from Kaiser Health News and NPR that will dissect and explain real medical bills to shed light on prices in U.S. health care and to help patients learn how to be more active in managing costs. Do you have a medical bill that you'd like us to see and scrutinize? Submit it here and tell us the story behind it.
RACHEL MARTIN, HOST:
We now have the story of a really large medical bill. It's a surprisingly common sort of charge, which is why we're examining it. Steve Inskeep spoke with Dr. Elisabeth Rosenthal of Kaiser Health News about the story of a $17,000 urine test. And Steve asked her who had to pay the bill.
ELISABETH ROSENTHAL: Oh, it was a young woman named Elizabeth Moreno who had some back surgery, a very common kind of surgery, and the surgery worked. And of course after her back surgery, you get a little prescription of opioids. People...
STEVE INSKEEP, BYLINE: Because if you need painkillers...
INSKEEP: ...You want to be careful with them.
ROSENTHAL: Right. And she took them for a few days - not very long. And then when she went for a follow-up visit about two months later, the surgery worked great. She was long off opioids. The doctor said, oh, well, we have to test your urine. Just pee into a cup. And boom - $17,850 bill.
INSKEEP: OK. So this is an extreme case. But it happens enough that NPR and Kaiser Health News have begun an investigation. We're going to be looking at big medical bills in weeks to come.
ROSENTHAL: So we want to understand - how do those charges get generated? How do they add up? - and in the process help all of those consumers/patients out there be better at reading their bills, be forewarned that they can get these kind of bills and also know the questions to ask so they don't end up being a victim like Elizabeth Moreno was.
INSKEEP: Let's focus on this $17,850 test. First, was that covered by the patient's insurance?
ROSENTHAL: No, it wasn't covered, to add insult to injury, because the lab that it was sent to was out of her insurance network. So the insurer's first answer was - oh, just out of network. They didn't even pass judgment on the bill. So first question to always ask is, is my sample being sent to an in-network lab or radiology facility?
INSKEEP: There's an issue of consent here because she obviously consented to a urine test but didn't consent to that expensive of one. And nobody asked her about which lab it was being sent to.
ROSENTHAL: Well - and poor patient, who would have thought you had to ask that? Some doctors would have said there's no real reason to have a urine test at all. I mean, this is a woman postoperatively who got some opioids, used them as needed and then, as far as everyone else knew and she said, she'd stopped.
INSKEEP: When you reached out to the doctor in this specific case or reached out to the lab, did they offer any explanation for why they felt this charge made sense?
ROSENTHAL: Well, the doctor wouldn't talk to our reporter. And it's unclear to me as a former physician. Did he understand when he sent this test off for a screen that it was going to be tested for 5,000 different things? Did he understand that that lab was going to do what it did? I don't know that answer, and he wouldn't talk to us about it.
The lab did respond. They said, basically, it's - we feel our charges are reasonable. Now, part of the problem and part of the reason you see all these huge price disparities is in this country, we don't have any standard for what's reasonable.
INSKEEP: What's an initial piece of advice you would give people if they have received a really large medical bill that they can't understand?
ROSENTHAL: Don't write the check.
INSKEEP: Don't pay?
ROSENTHAL: Don't pay first. Don't be intimidated. I mean, ultimately, you may be forced to pay more than you want. But first step is don't write the check.
INSKEEP: And another thing, of course, that you can do is share your stories with us. NPR and Kaiser Health News want to see some of your bills, whether they're sky high or just interesting, bills where there's a story to tell that we can investigate. If you'd like to participate, go to NPR's Shots blog, where you can tell us about your experiences and upload your bills. There's a form.
Elisabeth Rosenthal of Kaiser Health News, thanks very much.
ROSENTHAL: Thank you for having me.
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