Since the emergence of Covid-19, there have been over 14 million infections, over 8 million recoveries, and about 613,455 fatalities. While no cure or vaccine has been approved yet, different countries focus on ways to mitigate the spread of the virus. Covid-19 testing has been instrumental in mitigating the spread of the virus.
For this reason, incentives such as the one captured in the CARES Act have been rolled out to address the Covid-19 testing payment issues. One of the provisions captured in the Family First Coronavirus Response Act clearly states that Covid-19 testing must be included in commercial insurance plans, and cost-sharing must not be imposed. This means that persons covered by these plans should not make any out of pocket payments. However, entities such as a laboratory, clinic, or hospital that are out of network are allowed to do balance billing. This charges the patient the difference between the provider’s charge and the amount that the insurance company allows.
It is correct to say that the CARES act will impact Covid-19 testing prices of both in-network and out-of-network providers. It is worth noting that the market does not determine the Covid-19 testing prices, but rather set by the law. The goal is to ensure that the testing is offered free to the patients.
Whether the testing entities set this price high or low, there are no known constraints to this pricing. This means that there is a likelihood of the patients being balance billed if the provider decides to charge higher than the insurer will allow.
The out-of-network providers also have no reason to set the testing prices lower than the “cash price.” However, certain circumstances may lead them to do that. For instance, the provider can set a lower cost to secure a relationship with an insurer. Also, the price can be set lower to avoid public judgment and to create a good brand image.
The provisions provided in this case are meant to protect the patients from surprise balance billing. In essence, a patient is only responsible for cost-sharing in an in-network provider. On the other hand, it is up to an insurance company and an out-of-network provider to agree to Covid-19 testing pricing. In this case, the patient should not be bombarded with surprise billing.
This provision will, however, affect taxpayers and employers. Remember that if the provider is allowed to make their testing prices higher than the cash price, the insurer will have to incur this in one way or another. On the other hand, if the patient is testing for Covid-19 through an in-network provider, they will be responsible for the difference between the provider’s price and what the insurer is allowed to foot.
However, the absence of constraints in the CARES act will allow room for unethical actors to exploit.
Antigen tests will be billed by primary care clinicians and will be charged under in-network billing whereby the insurer and clinician get to negotiate the contract.
Paul Singh, MHA, BA
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