Mailbag! Mysterious fees and the semantics of “charity care”

Hey there —

This week we’re answering a couple reader questions that landed in our inbox recently. One is about those dreaded and increasingly common “facility fees” that show up on your medical bills. The other is about why we keep using the word “charity” even though it makes people’s skin crawl.

Plus, we’re introducing our team’s newest member: summer intern and graduate student Lynn Barbera. Let’s go!

Question: What’s up with these extra fees for doctor’s appointments and lab work?

Hi, I keep getting charged “outpatient hospital” copays for visits (from over a year ago!) that seem like regular dr appts. Sometimes it’s because the dr is affiliated with a hospital system, and sometimes routine lab work triggers extra charges. It’s really unclear ahead of time how visits will be billed, even when I ask. I’d love to hear an episode about why this happens, what patients can do to avoid surprise costs, and whether hospitals/insurers are required to disclose this information. — Danya, NY

Without seeing your bills or knowing more about what happened, my guess is that those “outpatient hospital copays” are a kind of facility fee, an extra charge hospitals tack onto bills to cover overhead.

Hospitals have a lot of overhead, to be sure. But as you’ve noticed, they’ll sometimes add these fees to bills for services that take place outside the hospital, too. They can tack this fee onto stuff that happens in any room in any kind of building affiliated with the hospital, even where you’d be hard pressed to find more than a paper-covered exam table.

And as big hospital systems keep buying up independent medical practices, these fees are getting harder and harder to avoid.

A couple of years ago, we looked at dozens of bills where facility fees showed up and talked with experts about a few tips that may help people avoid them or fight them.

One, as you mentioned, is calling ahead to ask whether you should expect a facility fee, and if so, how much it might be. Some states require hospitals to disclose this information publicly. But as you can attest, your mileage may vary.

Recently, the Public Interest Research Group (PIRG) called 40 hospital-affiliated providers in Oregon and found that only one clinic could say definitively that it charged facility fees and explain how much they would be. That’s a huge problem.

If you’re determined to avoid paying a facility fee, their report suggests getting care from an independent practice that isn’t affiliated with a hospital. Of course, depending on where you live or what kind of care you need, that may not always be possible.

For lab work, you may have more options. You can ask your doctor to send the order somewhere of your choosing, based on what your insurance covers. To avoid both a facility fee AND inflated prices, that probably means a place that isn’t tied to a hospital. Check out Dan’s tips for avoiding overpaying for bloodwork.

Another tip: Check whether your insurance plan even allows providers to bill you for facility fees. Hospitals and insurance plans operate under rules laid out in contracts, and you can’t always count on either the hospital billing department or the insurance company to follow those rules when the bill shows up.

It takes some internet sleuthing on your part, but you can review those rules in a big document called the reimbursement manual, often available online. Claire wrote about what keywords to look for here.

Q: Why do you call it “charity care?”

We lobbied hard to get the name changed in NY. We also stopped calling it “Charity Care.” It’s an IRS requirement, just like subsidies provided to farmers and tax breaks for billionaires. We don’t call it “Charity Care” for them, and we should not call nonprofit hospitals providing legally required financial assistance by that name. — Marcia, NY

“Charity” is a loaded word for a lot of people, and I totally get why you lobbied to ditch it in this context, here in my home state (go Knicks). A lot of people are uncomfortable with the idea that they might need charity. And at some hospitals, the income threshold to qualify for “charity care” is high enough that it includes people who might feel like they’re doing just fine — people who’ve never had to ask for help before getting socked with a gigantic medical bill.

Plus, charity is, by definition, voluntary. And, as you said, “charity care” is actually a legal requirement for nonprofit hospitals.

That said, there may still be an important reason to use the exact phrase “charity care” when you ask a hospital about an application. Jared Walker, founder of Dollar For, an organization that helps people apply, told us that when patients say “financial assistance” instead of “charity care,” providers sometimes redirect them to a payment plan, or worse: a medical credit card.

So for now, we figure it’s best to keep using the term in our work so people know what it is, and how to get it — even though it’s far from perfect.

Meet Lynn Barbera, our new intern

Our new summer intern started last week! Lynn Barbera comes to us by way of the Craig Newmark Graduate School of Journalism at CUNY (once again, go Knicks) and they’ve already made huge progress on one of our main summer reporting projects.

Lynn (they/them) is a freelance writer and comedian. Before journalism school, they worked as a producer on the indie podcast She’s All Fat, a show about fat positivity, and on their own labor of love: a show about crushes.

Between cold-calling a couple dozen sources this week for our upcoming project, Lynn took time to answer a few get-to-know-you questions.

What’s something you’re excited about this summer with An Arm and a Leg?

I’m excited to feel like I’m actually doing something with all of the anger and anxiety I personally have around health care costs! I definitely want to do some reporting in the queer/trans health care space and connect with queer/trans listeners of the show. Plus, I’ve missed working with a team, and I’m excited to get to know and learn from the arms and legs of An Arm and a Leg.

What’s one new thing you learned in your first week or so working with us?

I don’t have to already be an expert on the stories we’re working on???? This health care stuff is scary and confusing, and I definitely thought I might need a stronger footing to start reporting with An Arm and a Leg. But, over pizza on my first day, Emily and Claire gave me some assurance: part of reporting a story is talking to people who actually are the experts in their fields — and it can actually be helpful if you ask the basic questions that most non-experts wouldn’t know!

Current favorite activity outside of work?

Okay, this is a strange confluence of events, but I just started watching Breaking Bad for the first time — and I know I’m so, so very behind on that one. But until just now, I didn’t even consider how it’s ultimately a show about… what might happen when healthcare costs so freaking much! And wow, I see what everyone’s been talking about for 15+ years — this show rocks. I just put my AC in the window for the summer, so I’m looking forward to many cool nights with noodles and Mr. White.

Yep, it’s shaping up to be a pretty good summer. Speaking of which, we’re still taking recommendations for summer reading! Tell us what’s on your list.

— Emily