Ouch. That “free” annual checkup can cost you. Here’s why.

When Kristy Uddin, 49, went for her annual mammogram in Washington state last year, she assumed she wouldn’t incur any bills because the test is one of several preventive measures guaranteed to be free for patients by law on Affordable Care Act of 2010. The ACA provision made medical and economic sense, encouraging Americans to use screening tools that could solve medical problems in the first place and keep patients healthy.

So when a bill arrived for $236, Uddin — an occupational therapist familiar with how the health care industry works — complained to her insurer and the hospital. He even asked for an independent review.

“I say, ‘Tell me Why Am I getting this bill?’ Uddin recalled in an interview. The unsatisfactory explanation: The mammogram itself was covered under ACA rules, but the charge for the equipment and setup was not.

That response was especially distressing, she said, because a year earlier, her “free” mammogram at the same health system had run up a bill of about $1,000 for the radiologist’s reading. Although he fought that charge (and won), this time he threw in the towel and wrote the $236 check. But then he rejected a submission to the KFF Health News-NPR “Bill of the Month” project:

“I was really mad — it’s ridiculous,” she later recalled. “That’s not how the law should work.”

The designers of the ACA might have thought they had made it clear enough that millions of Americans would no longer have to pay for certain types of preventive care, including mammograms, colonoscopies and recommended vaccines, in addition to doctor visits to check for diseases. But the law’s drafters didn’t count on America’s ever-creative medical juggernaut.

In recent years, the medical industry has eroded the ACA’s guarantees, finding ways to charge patients in the law’s gray areas. Patients who go for preventive care, expecting it to be fully covered by insurance, are blindsided by bills, big and small.

The problem is deciding exactly what elements of a medical encounter are covered by the ACA warranty. For example, when do the conversations between doctor and patient during an annual visit for preventive services move into the realm of treatment? What screenings are needed for a patient’s annual visit?

A healthy 30-year-old visiting a primary care provider might get a few basic blood tests, while a 50-year-old who is overweight would deserve additional screening for type 2 diabetes.

To make matters more confusing, the annual checkup is guaranteed to be “no cost” for women and people age 65 and older, but the guarantee doesn’t apply to men ages 18-64 — although many preventive services that require a doctor’s visit (such as blood pressure or cholesterol checks and substance abuse checks) is covered.

It’s no wonder that what is covered under the umbrella of prevention can look very different to medical providers (trying to be thorough) and billers (looking to squeeze more dollars out of each medical encounter) than it does to insurers (who benefit from narrower definitions).

For patients, the gray area has become a minefield of charges. Here are a few more examples, which have come out of the Bill of the Month project in just the last six months:

Peter Opaskar, 46, of Texas, went to his primary care doctor last year for his preventive visit — as he had done before, at no cost. This time, his insurer paid $130.81 for the visit, but he also received a complicated bill for $111.81. Opaskar learned he had incurred the additional charge because when his doctor asked him if he had health problems, he said he had digestive problems but had already made an appointment with his gastroenterologist. So, the office explained, his visit was billed as both a preventive physical and a consultation. “Next year,” Opasker said in an interview, if asked about health concerns, “I’ll say ‘no,’ even if I have a gunshot wound.”

Kevin Lin, a technology specialist in Virginia in his 30s, went to a new primary care provider to take advantage of the preventive care benefit when he got insurance. he had no physical complaints. He said he was assured at check-in that he would not be charged. His insurer paid $174 for the checkup, but charged him an additional $132.29 for a “new patient visit.” He said he has made several calls to fight the bill, so far with no luck.

Finally, there’s Yoori Lee, 46, of Minnesota, herself a colon surgeon, who was shocked when her first colonoscopy yielded a $450 bill for a biopsy of a polyp — a bill she knew was illegal. Federal regulations issued in 2022 to clarify the issue are very clear that biopsies during screening colonoscopies are included in the no-cost promise. “I mean the whole point of the projector is to find things,” he said, perhaps stating the obvious.

While these patient accounts defy common sense, there is room for creative exploitation of the complex regulatory language surrounding the ACA. Consider this from Ellen Montz, deputy administrator and director of the Center for Consumer Information and Insurance Oversight at the Centers for Medicare & Medicaid Services, in an emailed response to questions and an interview request on this topic: “If a preventive service separately or not tracked as individual encounter data separate from an office visit and the primary purpose of the office visit is not to deliver the preventive component or service, then the plan issuer may impose cost-sharing for the office visit.”

So if the doctor decides that a patient’s report of stomach pain does not fall under the umbrella of preventive care, then can that aspect of the visit be billed separately and the patient has to pay?

And then there’s this, also from Montz: “Whether a facility fee is allowed to be charged to a consumer will depend on whether the use of the facility is an integral part of getting the mammogram or any other preventive service required to be covered without cost-sharing under federal law.”

But wait, how can you get a mammogram or colonoscopy without a setup?

Unfortunately, there is no federal enforcement mechanism to detect individual billing abuses. And the agencies’ remedies are weak — they simply instruct insurers to reprocess claims or tell patients they can resubmit them.

In the absence of stronger enforcement or remedies, CMS could likely clamp down on these practices and give patients the tools to fight back by offering the clarity the agency provided a few years ago on polyp biopsies—defining more clearly what falls under the category of preventive care, what can be billed and what can’t.

The stories KFF Health News and NPR are receiving are likely just the tip of the iceberg. And while each bill may be relatively small compared to the staggering $10,000 hospital bills that have become all too familiar in the United States, the sad consequences are manifold. Patients pay bills they don’t owe, depriving them of cash they could use elsewhere. If they can’t pay, these accounts can end up in debt collection agencies and ultimately hurt their credit score.

Perhaps most troubling: These windfall bills may discourage people from seeking out potentially life-saving screenings, which is why the ACA deemed them “essential health benefits” that should be free.