Samantha Liss, Kff Health News

Carmen Aiken of Chicago made an appointment for an annual physical exam in July 2023, planning to get checked out and complete some blood work.

The appointment was at a family medicine practice run by University of Illinois Health. Aiken said the doctor recommended they undergo a Pap smear, which they hadn’t had in more than a year, and testing for sexually transmitted infections. Aiken, who works for a nonprofit and uses the pronoun they, said they were also encouraged to get the HPV vaccine.

They’d tested positive for HPV in 2019 and eventually cleared the virus but had not received the vaccine to prevent future infections.

“Sounds like a good idea,” Aiken, 37, recalled telling the doctor.

They also needed some lab work done, part of routine monitoring for one prescription. After being examined, Aiken said, they were directed to a different part of the office building to get blood drawn and receive the first dose of the vaccine before leaving.

Then the bill came.

The Medical Procedure

Services at Aiken’s appointment included a pelvic exam, a vaccination, and blood work, checking, in part, glucose levels and liver function.

An annual physical exam typically includes a variety of services, many of which insurers are required to cover under the Affordable Care Act, such as reviewing the patient’s health history, screening for high cholesterol, or performing a Pap smear, a procedure to check the cervix for signs of cancer.

Updating immunizations is also a common, covered service at checkups. The vaccine for HPV, or the human papillomavirus, provides protection against an infection that can cause several types of cancer. Federal health officials recommend being immunized for HPV at age 11 or 12, though the vaccine also can be administered later in life.

The Final Bill

$1,430.13: $1,223.22 for lab services and pathology, plus $206.91 for “professional services,” which included a charge for a 40-minute “High Mdm” outpatient visit — indicating a high level of “medical decision-making” — as well as charges for immunization administration and vaccines.

The Billing Problem: Diagnostic Blood Work With a Hospital Price Tag

Not all services that may be provided as part of an annual physical are paid for by insurance as preventive care.

A patient who needs blood work for a specific medical concern — as Aiken did, for medication monitoring — could be required to pay part of the bill. That’s the case even if the blood work is performed during a checkup alongside preventive services. Some health insurers pay for standard blood work as part of a preventive visit, but that’s not always the case.

Aiken had purchased a health insurance plan on the federal marketplace and said they were confident the visit would be covered at no cost to them.

When they got a bill for more than $1,400, Aiken thought, “How did this happen?” They said they called their insurer, BlueCross BlueShield of Illinois, then filed an appeal for the $1,223.22 amount they owed for lab services after their initial inquiry went nowhere. “Surely this is a misunderstanding.”

But their insurer sided with UI Health’s position that the blood work rendered during the appointment was not preventive. In a letter denying Aiken’s appeal, BlueCross BlueShield of Illinois decided that “the labs were billed correctly as diagnostic.”

Under the plan’s parameters, the insurer determined Aiken remained on the hook for 50% of the cost of outpatient labs performed in a hospital setting.

Dave Van de Walle, a spokesperson for BlueCross BlueShield of Illinois, would not discuss Aiken’s bill with KFF Health News.

Francesca Sacco, a spokesperson for UI Health, said in an emailed statement that Aiken scheduled the appointment for “medication monitoring and to obtain a vaccine.”

“Medication monitoring is not considered a wellness benefit under the Affordable Care Act,” she said.

Sacco also said Aiken’s labs were sent for processing to University of Illinois Hospital, more than a mile away from the family medicine practice.

That left Aiken owing more. Hospitals typically charge much more than physicians’ offices or independent commercial labs for the same tests.

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More from Bill of the Month

The distinction between a preventive visit and a diagnostic one is important for billing purposes: It dictates who’s on the hook for the bill. A preventive visit generally comes at no cost to patients. But a visit for an ongoing medical issue is usually classified as diagnostic, leaving the patient subject to copays and deductibles — or even charged for two separate appointments.

Patients may not notice a difference in the exam room. Much of that nuance is determined by the medical provider and captured on the bill.

Confusion still persists 15 years after the ACA’s preventive services protections took effect, said Sabrina Corlette, a founder and co-director of the Center on Health Insurance Reforms at Georgetown University.

“This is an outrageous bill for what should have been routine care,” Corlette said. “People just don’t have this kind of money lying around.”

The Resolution

After the insurer denied their appeal, they “fell down a hole into despair about it for a while,” Aiken said.

“And then someone really wise was like, ‘You can pay it and then just stop thinking about it.’”

So that’s what Aiken did: “I put it on my credit card.”

UI Health’s Sacco said the hospital system is committed to working with insurers to resolve cost-sharing disputes.

“However, it is the insurance company’s sole discretion whether a service is fully covered or subject to cost sharing,” she said. “In this case, the insurer determined that cost sharing would be applicable to a specific portion of the services provided to the patient. Based on this determination, the patient was billed accordingly by UI Health.”

The experience left its mark on Aiken. Last year, they said, they walked out of an urgent-care visit after a doctor recommended a Pap smear — fearing they’d incur another large bill.

The Takeaway

Delaying or avoiding care can lead to worse outcomes, which is why lawmakers tried to ensure patients generally would pay nothing for preventive services, such as immunizations, under the ACA.

Annual checkups are a key element of preventive care. For instance, most adults who never received the HPV vaccine do not know they are still eligible, so it’s critical to inform them of their options, said Verda Hicks, a gynecologic oncologist based in Kansas City, Missouri.

The vaccine offers protection against nine types of HPV, she said. It also prevents HPV-related cancers in men, so the Centers for Disease Control and Prevention recommends boys receive the immunization, too.

“Get vaccinated,” Hicks said. “We just do not have the same tools for many other cancers.”

Keep in mind that your coverage may vary — some insurance companies won’t cover the cost of the vaccine for some older patients — and the same services may be subject to different cost-sharing rules depending on whether they are conducted for prevention versus diagnosis.

Also, prices can vary depending on where care is delivered and tests are performed. If you need a blood test, ask that your doctor send the requisition to a commercial, in-network lab. Patients may not realize that labs drawn at a clinic may be sent to a hospital for testing, exposing them to greater costs.

There has been a push in Congress to eliminate this price variation through “site-neutral” payment policies. Regardless of location, the price for routine care would be reimbursed at the same amount.

“Site-neutral reforms could potentially have significantly reduced Carmen’s expenses,” said Christine Monahan, an assistant research professor at Georgetown’s Center on Health Insurance Reforms.

Meanwhile, a case before the Supreme Court could upend the health system by eliminating the requirement that insurers cover preventive services like vaccines and annual screenings at no cost to patients. The high court heard oral arguments April 21.

If the justices side with the plaintiffs this term, Georgetown’s Corlette said, “then we all potentially lose access to free, high-value preventive care, and that would be a real shame.”

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This article first appeared on KFF Health News and is republished here under a Creative Commons license.

If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

Overcome by worries, Lynette Isbell dialed a mental health hotline in April 2022. She wanted to talk to someone about her midlife troubles: divorce, an empty nest, and the demands of caring for aging parents with dementia.

“I did not want to keep burdening my family and friends with my problems,” Isbell said.

But she didn’t find the sympathetic ear she was hoping for on the other end. Frustrated, she hung up. Little did she know ending that call would set off events she would regret.

Police arrived at her home in Terre Haute, Indiana, handcuffed her, and had her committed to a hospital, records show, resulting in more than $12,000 in hospital charges.

“The whole thing was an absolute, utter, traumatic nightmare,” she said.

Isbell’s call for help represented the need for a new approach to crisis calls just as the nation was readying to flip the switch to a revamped response system for mental health. Using just three digits — 988 — people could call or text for help from anywhere at any time starting in July 2022. Federal officials viewed the launch of 988 “as the linchpin” to reenvision the mental health crisis system. The idea was to reduce the reliance on police and the burden on emergency rooms, while eliminating the stigma of seeking help.

But recent federal funding and staffing cuts undermine the future of the 988 program and threaten to erase progress made in Indiana and elsewhere, mental health advocates said.

The Trump administration cut staffing at the Substance Abuse and Mental Health Services Administration, the federal office that oversees 988, in recent weeks. It also ended $1 billion of its grants that a number of states relied on this year to help fund their 988 systems, said Stephanie Pasternak, state affairs director of the National Alliance on Mental Illness. While a judge temporarily paused grant cuts for 23 states that contested them, the trims to other states — including Indiana — have moved forward.

Between the SAMHSA cuts and potential reductions to Medicaid, another crucial funding stream for these services, Pasternak and others are concerned about what this means for 988’s future.

Any disruption to federal funding streams is “gravely impactful,” said Zoe Frantz, CEO of the Indiana Council of Community Mental Health Centers. “We have put a lot of time, talent, and treasure — from the state to providers — in trying to build the system,” Frantz said. “We can’t go back.”

After Isbell hung up her call, a member of the Suicide Prevention Hotline, the crisis line formerly available, phoned the Vigo County Sheriff’s Office and told a dispatcher Isbell was “thinking of committing suicide,” according to the sheriff’s report obtained by KFF Health News.

Years later, Isbell maintains she never said this. “I’ve never been actively suicidal.”

But two officers drove to Isbell’s home.

When they arrived, Isbell was sitting on her back porch on a sunny day with trees just starting to bud. The officer’s report alleged she admitted to thinking about driving her car into a tree, wanting doctor-assisted suicide, and fantasizing about a semitruck hitting her.

She contends active suicidal ideation with a plan is different than the overwhelmed feelings she had that day.

“It was like a childhood game of telephone, only not at all funny,” she said. What she said became distorted and left her no recourse.

The officers walked her to a squad car, where they handcuffed her before transporting her to Terre Haute Regional Hospital, according to dashcam video obtained from a public records request. Neighbors watched as she was taken away.

“I don’t know why I needed to be handcuffed,” she said. “It was demoralizing.”

The Vigo County Sheriff’s Office did not respond to requests for comment about Isbell’s case.

Isbell said being hospitalized against her wishes humiliated her and forced her to battle confusing medical bills for months. An itemized bill shows the hospital charged $12,772 for her overnight stay. After insurance, Isbell was on the hook for roughly $2,800. By comparison, a one-night stay in the presidential suite at the new Terre Haute Casino Resort is $2,471. Terre Haute Regional Hospital spokesperson Ann Marie Foote said Isbell’s bill was “discounted down” to $1,400.

“Our highest priority is always the safety and well-being of patients,” Foote said.

According to Isbell’s medical records, doctors there said “she was very stressed” and “just wanted to speak to someone” and reiterated “she was not suicidal.” They said her anxiety “is increased and made worse by being in here.”

She had “anxiety” and a “depressed mood,” and, according to medical records signed by a psychiatrist there, “she does not meet current criteria for involuntary hospitalization.” She was discharged the next day.

Upset by how she was treated, she contacted 988, the sheriff’s office, and the hospital.

In response to KFF Health News’ questions about Isbell’s experience, Michele Holtkamp, a spokesperson at the time for Indiana’s Family and Social Services Administration, said that before the launch of 988, “the state did not have oversight of individual crisis lines and how they responded.”

After 988 began, Isbell received a follow-up email from an executive with Mental Health America, introducing her to the director of Indiana’s 988 hotline, Kara Biro.

“I shared your story with her and we agree that we would love to get you to help with a training video,” wrote Brandi Christiansen, CEO of Mental Health America-Wabash Valley Region. She explained it would provide workers an opportunity to understand the real-life implications an “outcall can have on a human being.” The video has yet to happen, Isbell said.

The sheriff’s department also asked for her input to improve the process, she said.

Isbell saw those as signs of a turnaround. For mental health leaders in Indiana, 988 represented a “springboard to transform and build” a new response system, according to a 2022 Indiana Behavioral Health Commission report. Too often, the report said, Indiana’s “ineffective and inefficient” system had relied heavily on police and emergency rooms.

Before 988, the state hotline also relied almost entirely on volunteers, complicating efforts to standardize responses, said Jay Chaudhary, a former director of Indiana’s Division of Mental Health and Addiction, who led the state’s transition to 988.

“When somebody makes the really brave step to seek help with mental health care, that system better be ready to catch them,” he said.

Today, Indiana ranks among the 10 states with the highest 988 answer rates, a sign it can handle the demand, said Laurel Stine, chief advocacy and policy officer with the American Foundation for Suicide Prevention.

In Indiana, behavioral health professionals now lead the response via mobile crisis teams, not law enforcement, such as the officers who handcuffed Isbell.

As of July, mobile crisis teams were available to 4.8 million people living in 65 of Indiana’s 92 counties, reaching roughly 71% of residents, according to a 2024 report from the behavioral health commission. In the first half of last year, mobile crisis teams were dispatched 3,080 times for help. Law enforcement officers were involved in about 1% of those cases and roughly 10% resulted in a trip to the emergency room, according to the report.

Similar efforts have occurred nationwide since the 2022 launch. The 988 hotline received 4.8 million calls, texts, and chats during its first year, which is roughly nine times a minute, according to Substance Abuse and Mental Health Services Administration data.

But the federal government has terminated numerous grants earmarked for Indiana and other states to tackle mental health and substance use issues. Still, SAMHSA spokesperson Danielle Bennett said the 988 hotline is a “critical function” and that the federal government “will never compromise” protecting people experiencing a crisis. The hotline, Bennett said, “continues daily, life-saving work.”

The Indiana agency tasked with overseeing 988 had more than $98 million in SAMHSA grants but received 73% of that as of March 24, when the grants were terminated, according to a government list of cuts. That leaves Indiana $26 million short.

Some federal grants were passed through to local organizations, including one group that received grant money for “mobile crisis units,” according to an online grant summary. In a statement, Indiana Family and Social Services Administration spokesperson James Vaughn confirmed it received notice of the terminated SAMHSA grants but declined to provide details other than to say it is “working to minimize the impact to Hoosiers.”

Isbell hopes the 988 option doesn’t disappear for those who need a hand, not handcuffs.

She dealt with the fallout of that fateful call for a long time. After more than a year, she said, she paid the $1,400 bill to put the ordeal behind her.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

Subscribe to KFF Health News' free Morning Briefing.

This article first appeared on KFF Health News and is republished here under a Creative Commons license.