Alexa Kasdan had a cold and a sore throat.
The 40-year-old public policy consultant from Brooklyn, N.Y., didn’t want her upcoming vacation trip ruined by strep throat. So after it had lingered for more than a week, she decided to get it checked out.
Kasdan visited her primary care physician, Roya Fathollahi, at Manhattan Specialty Care, just off Park Avenue South and not far from tony Gramercy Park.
The visit was quick. Kasdan got her throat swabbed, gave a tube of blood and was sent out the door with a prescription for antibiotics.
She soon felt better, and the trip went off without a hitch.
Then the bill came.
Patient: Alexa Kasdan, 40, a public policy consultant in New York City, insured by Blue Cross and Blue Shield of Minnesota through her partner’s employer.
Total bill: $28,395.50 for an out-of-network throat swab. Her insurer cut a check for $25,865.24.
Service provider: Dr. Roya Fathollahi, Manhattan Specialty Care.
Medical service: lab tests to look at potential bacteria and viruses that could be related to Kasdan’s cough and sore throat.
What gives: When Kasdan got back from the overseas trip, she says there were “several messages on my phone, and I have an email from the billing department at Dr. Fathollahi’s office.”
The news was that her insurance company was mailing her family a check — for more than $25,000 — to cover some out-of-network lab tests. The actual bill was $28,395.50, but the doctor’s office said it would waive her portion of the bill: $2,530.26.
“I thought it was a mistake,” she says. “I thought maybe they meant $250. I couldn’t fathom in what universe I would go to a doctor for a strep throat culture and some antibiotics and I would end up with a $25,000 bill.”
The doctor’s office kept assuring Kasdan by phone and by email that the tests and charges were perfectly normal. The office sent a courier to her house to pick up the check.
How could a throat swab possibly cost that much? Let us count three reasons.
First, the doctor sent Kasdan’s throat swab for a sophisticated smorgasbord of DNA tests looking for viruses and bacteria that might explain Kasdan’s cold symptoms.
Dr. Ranit Mishori, professor of family medicine at the Georgetown University School of Medicine, says such scrutiny was unnecessary.
“In my 20 years of being a doctor, I’ve never ordered any of these tests, let alone seen any of my colleagues, students and other physicians order anything like that in the outpatient setting,” she says. “I have no idea why they were ordered.”
The tests might conceivably make sense for a patient in the intensive care unit or with a difficult case of pneumonia, Mishori says. The ones for influenza are potentially useful, since there are medicines that can help, but there’s a cheap rapid test that could have been used instead.
“There are about 250 viruses that cause the symptoms for the common cold, and even if you did know that there was virus A versus virus B, it would make no difference because there’s no treatment anyway,” she says.
(Kasdan’s lab results didn’t reveal the particular virus that was to blame for the cold. The results were all negative.)
The second reason behind the high price is that the doctor sent the throat swab to an out-of-network lab for analysis. In-network labs settle on contract rates with insurers. But out-of-network labs can set their own prices for tests, and in this case the lab settled on list prices that are 20 times higher than average for other labs in the same ZIP code.
In this case, if the doctor had sent the throat swab off to LabCorp ― Kasdan’s in-network provider ― it would have billed her insurance company about $653 for “all the ordered tests, or an equivalent,” LabCorp told NPR.
The third reason for the high bill may be the connection between the lab and Kasdan’s doctor. Kasdan’s bill shows that the lab service was provided by Manhattan Gastroenterology, which has the same phone number and locations as her doctor’s office.
Manhattan Gastroenterology is registered as a professional corporation with the state of New York, which means it is owned by doctors. It may be the parent company of Manhattan Specialty Care, but that is not clear in its filings with the state.
Fathollahi, the Manhattan Specialty Care physician, didn’t answer our questions about the bill. Neither did Dr. Shawn Khodadadian, listed in state records as the CEO of Manhattan Gastroenterology.
The pathologist listed on the insurance company’s explanation of benefits is Dr. Calvin L. Strand. He is listed in state records as the laboratory director at Manhattan Gastroenterology and Brookhaven Gastroenterology in East Patchogue, N.Y. We tried to reach him for comment at both places.
Even though Kasdan wasn’t stuck with this bill, practices like this run up the cost of medical care. Insurance companies base premiums on their expenses, and the more those rise, the more participants have to pay.
“She may not be paying anything on this particular claim,” says Richelle Marting, a lawyer who specializes in medical billing at the Forbes Law Group in Overland Park, Kan., who looked into this case for NPR. “But overall, if the group’s claims and costs rise, all the employees and spouses paying into the health plan may eventually be paying for the cost of this.”