As if the petri dish of COVID-19 wasn’t crowded enough with physical and mental pain, many who get the virus and recover face not only income loss, but also out-of-pocket expenses associated with the infection.

Rich Alperin, a heavy equipment operator in New Hampshire, passed out at work at the end of March and spent the next two weeks bedridden with COVID-19. He was told by his insurance company that all related expenses would be covered 100%.

But after statements recently started arriving with large charges, including a nearly $500 copay for emergency room admittance, he called his insurance company and learned that full coverage applies only to expenses incurred during the time of active illness — and not for the follow-up care he has needed for breathing, urinary and foot problems.

“There are all kinds of tricks and games the insurance companies are playing in order to keep their money,” Alperin, a member of the grassroots Facebook group called Survivor Corps, told The Gazette. “That’s what they’re in business for — to hold on to their money.”

Under the nation’s complex health care system, how much COVID patients will owe depends on their insurance plan and the state in which they live. 

While many health-insurance companies have been waiving costs to covered patients for hospitalization and treatment, caveats, billing errors and a lack of clarity on what’s covered are leading to unexpected bills, say people on the online Survivors Corps forum, where COVID patients share battle stories, develop camaraderie and spread the word about ongoing challenges the disease can bring.

From Washington, D.C., to Kansas, some of those afflicted by the disease say they owe thousands of dollars, while others from New York to California report that they paid nothing or only nominal amounts on unfathomable bills.

An uninsured Colorado man said he wasn’t charged anything for hospitalization, but he has accumulated about $2,000 in out-of-pocket expenses for equipment, prescriptions, lab work and X-rays.

While most insurance companies are not billing patients for inpatient COVID treatment, out-of-pocket expenses still depend on individual coverage, said Dr. Renna Becerra, an internist with UCHealth Memorial Hospital in Colorado Springs.

“If you do not have a comprehensive plan, for instance Medicare beneficiaries without supplemental insurance or high-deductible insurance, then hospital bills to treat your COVID infection may be overwhelming,” she said.

“When you couple that with the loss of household income, it can be staggering for many families.”

Dispensing with copays

In addition to federal emergency regulations under the Families First Coronavirus Response Act and the Coronavirus Aid, Relief and Economic Security, or CARES, Act, states also have enacted pandemic policies, in an attempt to equalize services for COVID patients.

Colorado insurers began adjusting costs for COVID patients before government regulations doing so took effect in the spring, said Amanda Massey, executive director of the Colorado Association of Health Plans, which represents 11 health plans that cover 3 million Coloradans

Many Colorado insurers have dispensed with copays for testing, diagnoses and treatment, she said.

Carriers also have suspended preauthorization for various phases of treatment, eliminated in-patient admission charges for treatment and complications, provided free telehealth appointments and delivery for prescriptions and given other breaks.

“Health plans want to make sure members are getting high-quality, effective care for COVID-19, and they’ve been working diligently to ensure that,” Massey said.

Kaiser Permanente, a nonprofit insurer in Colorado, has waived all member out-of-pocket costs for COVID-19 treatment for both inpatient and outpatient services since April 1, said spokesman Christopher Gallegos.

With the belief that “cost should not be a barrier,” Gallegos said Kaiser also is not charging copays, deductibles or coinsurance for COVID screening or testing, including the cost of the visit, associated lab tests and radiology services.

Colorado insurers will reevaluate this month whether to approve another extension on such savings programs, Massey said. The first extension was granted in May and runs through Dec. 31.

“Their main concern is people accessing the care they need,” she said.

The national public health emergency period is currently scheduled to end Jan. 20.

A billing nightmare

Costs for COVID patients who don’t have health insurance are being paid for with federal CARES Act relief money.

Insurance companies have not gotten any federal relief funding, Massey said.

Colorado hospitals have received an estimated $500 million to $1.2 billion in relief funding, said Julie Lonborg, senior vice president of the Colorado Hospital Association, which represents 100 hospitals and health systems statewide.

“Early on, there were two things most of the payers said they would cover: the costs of testing and care, so that there was little, if any, out-of-pocket costs for patients,” she said. “The goal was so patients didn’t end up with large bills.”

Depending on what insurance companies decide to reimburse, patients “may or may not have out-of-pocket expenses,” Lonborg said, even if they have a high-deductible plan.

“A lot of patients did not owe anything, and won’t,” she said.

Medical costs are not usually assessed by an individual disease but by specific treatments and procedures, the equipment used, physicians’ time and room-and-board for in-patient hospitalization, Lonborg said. Thus, costs can “vary dramatically” by hospital and location.

As a new disease that can involve various treatments, COVID presented a billing nightmare, Lonborg said.

“The first rounds of bills were all wrong because the right codes weren’t being used, and most of the bills were scrubbed because they weren’t accurate,” she said.

Medicare announced it would pay hospitals a 20% allowance on top of standard Medicare rates for COVID diagnoses, for respiratory infections, for example.

In Colorado, Medicare normally reimburses 71 cents on the dollar; Medicaid pays 77 cents on the dollar. The latter is now 84 cents on the dollar for COVID billings.

“There were questions early on about whether the hospitals were making money — were they diagnosing more patients with COVID than they should?” Lonborg said.

“No, we were not and are not.”

In fact, some hospitals are returning some of the federal funding they received, she said, including an HCA Healthcare system member hospital in the Denver area.

“Right now, most (hospitals) are still sorting out what the money is allowed to cover,” Lonborg said, “and they’re still trying to figure out what their expenses have been. If the federal government says they can’t use it on capital equipment, more may give it back.”

‘Ventilation is a tipping point’

Some people may have COVID and not know it.

The majority — 80% — who get COVID will ride out the virus and recuperate at home, Lonborg said.

They might use over-the-counter cough syrup and pain relievers, and along with fluids, chicken soup and plenty of rest, will recover.

Fifteen percent of people need to be hospitalized for a handful of days, while receiving symptom monitoring, supplemental oxygen, prescription medications and other services.

Just 5% of people who contract COVID, who often have underlying health conditions, become critically ill, Lonborg said. They require intensive-care treatment, which is the most expensive because it involves 24-hour nursing, monitoring and interventions such as ventilators.

“Ventilation is a tipping point,” Lonborg said. “It’s among the highest-level of care. It’s round-the-clock people coming and going to make sure the patients get well.”

The good news, she said, is that the length of stay for ICU patients in Colorado has decreased because “we’ve gotten more efficient and more effective,” she said. “We’ve learned a lot.”

Lengths of stay for ventilated COVID patients among all Colorado hospitals averaged 22.5 days in the spring, and fell to around 17 days in the summer, she said.

In November, Colorado hospitals reported an average of 14 to 18 days of stay for critical patients and five to six days of hospitalization for lower-level supportive care.

That has decreased hospital charges, some of which are based on the patient’s condition and not the length of stay.

Average charges nationally for the top two most common respiratory diagnoses for COVID are $97,000 and $194,000, Lonborg said, no matter how long a patient is in the hospital.

As for treatments, one dose of remdesivir, an antiviral medication, for Medicaid and Medicare patients is $390, and $500 per dose for private insurance companies, the health plan association’s Massey said.

A patient needs six doses for one treatment period. Costs for administration of the drug are added on, she said, based on the contractual rates health insurers have established with providers.

Elective surgeries postponed

Health insurers set premium rates to cover the cost of claims one year in advance, based on medical and pharmaceutical trends and did not foresee the pandemic when they determined this year’s plan rates in October 2019, Massey said.

Costs are negotiated between insurance carriers and medical providers. One-third of Colorado residents are insured under Medicaid or Medicare. Another one-third are covered under individual or fully-insured small-group plans, and the final one-third are self-insured large-employer plans that are governed by a different federal law.

Because many elective surgeries, normal health care appointments and other therapies have been postponed over the course of the pandemic, in many cases, health carriers haven’t paid out the number of claims they anticipated for this year, she said.

Sometimes, insurers overestimate or underestimate; but if they don’t spend 80 cents, if a small-group employer, or 85 cents, if a large-group employer, of every premium dollar on claims and expenses that improve health care in a given year, they must issue refunds to customers, to limit profits and the amount they spend on administrative costs. That medical-loss ratio is based on a three-year average.

“It remains to be seen what this (COVID) will do long term to the market,” Massey said. “We are one part of the health care system, and we’re not going to profit off the pandemic.”

Representatives from both the Colorado insurance and hospital associations say the human toll of the virus is far greater than the economic consequences.

“The health care costs pale in comparison to the deaths and the people who have been hospitalized,” the hospital association’s Lonborg said. “The focus should be what do we need to do to slow the growth.

“We’re managing the volumes we have now, but it’s not going to last. We will run out of options at some point, if this continues.”