covid-19 testing

COVID Tests Should Be Covered. Insurance Companies Are Using Sneaky Workarounds

Insurance companies are trying to find dirty little tricks to avoid covering COVID-19 tests, setting up yet another kind of public health crisis.
October 28, 2020, 4:26pm
A woman in a brown hoodie with her blonde hair pulled back in a bun and a face mask lowered to her chin receives a nasal swab from a medical worker (not pictured except for their blue-gloved hand).
A woman is tested for COVID-19, October 2020, New York City. Photo via Getty Images

During this hellish pandemic season, there have been a few, barely visible silver linings.  One of them is the availability—in theory—of accurate testing, the knowledge that a swab up your nose or down your throat can help keep everyone a little safer. In Los Angeles, where I live, COVID-19 testing is fairly accessible through both drive-through and walkup locations, and the turnaround time for results is usually about 24 to 36 hours. And as is federally mandated under the CARES act, my insurance company, Cigna, has covered the full cost of those tests. That changed a couple months ago, when I received a letter informing me I owed $250 for a diagnostic PCR test. And then—a few weeks after Cigna’s communications professionals assured me this was all a big, silly misunderstanding—I got another letter, telling me the cost was actually $325.

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I’m not alone: Many private insurance companies have been eager to slime their way out of the cost-sharing they’re legally required to do for COVID testing, coming up with a variety of creative excuses for why they’re not legally required to cover your test. People across the country have complained they’re getting surprise bills, which can often take time and a lot of yelling on the phone with customer service to sort out. Not everyone has that time, or knows it’s possible to argue your way out of an unjustified bill. On both a regulatory and an individual level, testing costs are a mess: One colleague in New York recently got a letter stating she’d be charged $50 for a COVID swab; another got a similar notice of a $250 charge for an antibody test, which is also supposed to be covered in full. A friend with a different insurer was told she’d have to pay $75 because she hadn’t gotten tested through her primary care doctor—even though her primary care provider doesn’t provide COVID testing and had sent her to a city-run site where she lives.

To make matters worse, many health insurers have said they will stop cost-sharing for COVID tests between October and January, meaning that for many people, testing is probably about to get much more expensive. (A rundown of what many insurers have said they planned to do can be found here, but the overall price of COVID testing for an individual person after cost-sharing ends is still unclear.)

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That is, to put it mildly, a problem. Testing is important. It’s one of the most important tools we have to keep ourselves and others safe, gives some momentary peace of mind, and provides public health experts with insight into just how frighteningly fast the virus is spreading.  The timing for this sudden rush of surprise bills couldn’t possibly be worse, hitting just as flu season ramps up, and as we’re already seeing a surging COVID case rate across the country.

“Anything that reduces testing is absolutely a subject for concern,” said Justin Lessler, an associate professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health. “Our ability to control the virus with anything other than blunt measures, like shutdowns, is dependent on our ability to identify cases. So I would argue that what we would want is to make testing more accessible, not less.”

I’ve gotten tested routinely over the last few months, in part because both my partner, a photojournalist, and I come into contact with strangers as part of our jobs, and in part because we’re in a pandemic. Many countries that are not the United States have undertaken population-wide or mass testing of various kinds, including Iceland, Luxembourg, and the United Kingdom. It’s widely viewed as a key way to control the spread of the disease, get a better sense of how it’s transmitted, and to know when it’s under control, and not just hidden from our sight.

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But in early September, I received an explanation of benefits, or EOB, from Cigna for a test I’d taken on August 4, that was curious in several ways. (An EOB is not a bill, but an explanation of what you owe versus what your insurer has covered. I haven’t yet received an actual bill for a COVID test, but an EOB generally indicates that a bill is on the way.)

As with every other test I’ve taken thus far during the pandemic, I wasn’t experiencing serious symptoms, but was concerned about possible exposure. (To complicate matters, many people in California are experiencing chronic sore throats and other symptoms from wildfire smoke, making it incredibly difficult to tell whether you feel sick because of the global pandemic or because the state is routinely on fire.)

My test was conducted by Curative, the company that’s been responsible for the bulk of COVID-19 testing sites in Los Angeles, and where I’ve gotten tested almost every time I’ve gone. An identical test had been fully covered in the past. But the EOB declared that my testing had been determined to be “not medically necessary.”

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“This testing is considered medically necessary when an individual has a high risk of, or signs or symptoms of, a COVID-19 infection,” the EOB read.  “Your testing was not medically necessary based on the diagnosis, or diagnoses sent with this bill.”

This is, plainly put, nonsense. The CARES Act does not only cover COVID testing when you’re symptomatic, or at high risk, or displaying symptoms, or when it’s raining on alternate Tuesdays, or any other temperamental little measure. But the EOB also claimed elsewhere that Cigna was charging me for something else altogether. It said the laboratory where my test had been processed was “out of network,” something I have no control over.

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“Under the CARES Act your insurance must cover the cost of COVID-19 tests with no copay or deductible. We’ve seen most insurance companies provide great coverage and easy service,” Fred Turner told VICE News in a Twitter conversation. He’s the 25-year-old founder of Curative, and said that the CARES Act mandates that insurers cover both the test itself and the lab where it’s processed. “Laboratories don’t get to bill separately for them,” he said. “There is one CPT code that covers everything (reagents, consumables, labor, overhead, etc.). So when we bill Cigna, that is for both the test and the processing of the test in our lab.”

Turner said that while some insurers have been “really great” about covering tests efficiently, others, especially Cigna, have not. “The biggest thing we’ve seen is them trying to get out of testing asymptomatic people,” he said, “even if they are potentially exposed, in high risk areas or high risk employment (like trying to get out of testing nursing home employees!)”

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Cigna claims they’ve been attentive about protecting customers from surprise bills. When contacted for comment, they attributed all of this to a coding error that Curative was responsible for.

“Cigna covers and has waived cost-sharing for COVID-19 testing for both symptomatic and asymptomatic individuals with a variety of exposure risks, based on guidance from clinical guidelines from the FDA, the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and published professional society recommendation,” Elinor Polack told me; she’s the senior director for external affairs at Cigna. “This applies to both in and out-of-network providers.” The issue with my test, she said, was with the diagnostic code that Cigna’s lab used. “We also depend on laboratories to use the appropriate diagnostic codes, and we are working very closely with these partners to ensure they are submitting claims properly.  Denials of coverage can be driven by errors or omission of necessary information to process a claim. In this scenario, we quickly work with customers and providers to ensure a timely reimbursement.”

Despite these many assurances, in mid-September, I got another letter from Cigna. This one claimed that the cost of that same August test had changed: I now owed $325. But this time, Cigna offered to connect me with a company called Data iSight “to lower what you may owe.”  (To be clear, what I owe, legally, is $0, and if you’ve received a bogus COVID testing bill, that’s what you owe too.)

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When I called about this latest letter, Cigna transferred me to a “special team” of representatives, one of whom told me that the claim had to be sent for “adjustment”—something I’d been told had already happened, the last time I called. The representative also claimed that there was a difference between “diagnostic” and non-diagnostic testing, and that Cigna had begun charging for the latter in August, which does not make sense. A PCR test is by definition a diagnostic test, to determine if you have COVID; the other kind is an antibody test, which, as mentioned above, should also be covered in full.

“From March till August we were paying everything at 100 percent,” the representative told me. “After August 1, they said now we have two groups of people, diagnostic group and non-diagnostic groups. For diagnostic, it’s covered at 100 percent and for non-diagnostic, [they] denied the claim for medical necessity and [are] writing it off for medical necessity. That’s now till the 31.” After the 31, “they might continue where we’re at right now or make it even more limited where we’re only paying people who have a positive case of COVID.” (It’s possible the person I spoke to was making a distinction between PCR and antigen tests, which are the rapid tests that can be less accurate, but Cigna clearly states it covers both, as long as the tests are FDA-approved.)

All that is, to put it mildly, alarming: it means people will avoid getting tested due to the fear of the cost. Lessler, of Johns Hopkins, said that his best advice is to exercise appropriate caution if you’re having symptoms.

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“I would caution anyone not to over-interpret negative tests to start with,” he explained. “If you’re symptomatic, you want to be self-isolating regardless of whether or not you’ve had a positive test.”

For now, the representative from Cigna told me, diagnostic testing would be covered. After October 31, she couldn’t say: “If you’re getting COVID tests after the 31st, call us back,” she said, “and we’ll give you a rundown of the new guidelines.”

In the meantime, a look at Cigna’s claims portal shows that I have two COVID testing claims that are still “processing:” one for an August 4 test and one for one done in mid-September. Both claims say that how much I personally owe is “not yet available.”

While I’m certainly looking forward to learning how much Cigna thinks I should pay going forward to help protect myself from a highly infectious and often deadly disease, in a perfect world, I wouldn’t be calling a private health insurer to try to get permission to take a test at all. Lessler said that the fact that testing is “driven by individual preference” isn’t ideal.

“If one of the biggest values of testing is public health, we should be treating it as a public health measure,” he told me. “And once we’re in a position where people are responsible for their own testing, having them not be able to do so for fear of the financial consequences, it’s not desirable.”

Testing, Lessler added, “should be as widely available as possible and as integrated into the public health system as possible. It’s our best bet at controlling this thing.”