Are hospitals and clinics losing money by testing patients for COVID-19? I am not going to pretend this is a simple answer…but in general, YES.
But how does this happen if testing is covered for all and/or free? Two major legislative efforts passed at the onset of the pandemic in March 2020, the FFCRA and CARES Act requires health coverage for Covid-19 testing – including the testing, the related visit, and other services related to testing. Federal laws also made resources available to finance free testing for uninsured individuals but does not guarantee access to testing the uninsured. In addition, COVID-19 testing has been the the centerpiece for managing this pandemic with recommendations that we likely cannot do enough testing to get this pandemic under control. This would lead someone to believe that if you just offer testing in your hospital or clinic, they will come and we will get paid and all will be well. Not so!
Despite conspiracy theories that hospitals are cashing in on COVID-19, the entire medical system is strained with shifted/reduced revenue coupled with increased expense/inefficiencies. Aside from shut down itself, reduced surgeries volume, reduced office income with telemedicine, and significant PPE and preventive measures makes it very difficult to cash flow. Some 8% of U.S. doctors reported shuttering their practices in the past four months because of the coronavirus, according to an August Survey published by the nonprofit Physicians Foundation. More than 40% reported cutting staff. This is occurring while many large health insurance companies have posted huge profits during the same period. Clinics and hospitals need to change what they are doing to make ends meet but must not sacrifice quality of care in that effort.
So is there a way to perform a quality COVID-19 test for all patients and not end up in the red? The baseline cost of the PCR test charged by the labs is significant. I can share my personal experience as physician who offers testing in my clinic to prove my point. At the onset of the pandemic, I was committed to providing my patients and community the ability to test without exorbitant screening. Unlike the nearby systems at the onset of the pandemic, I felt if patients thought they needed testing, I was there to deliver. Little did I know that our reference labs we send specimens to would charge us $119 per PCR test. Our average reimbursement from insurance companies was $53 leaving us a deficit of $66 per test! Given the loss of our normal clinic volume and services this was not sustainable. This did not account for our uninsured charity cases we provided. I anticipate the big system down the street with the drive thru NP swab technique breaks even at best. A nurse performs the specimen collection and no office visit is being charged. We performed NP swabs and NP aspirates and learned quickly that NP aspirates were the way to go. We were able to recoup some of the cost if a provider was able to see the patient in our designated testing room and an E and M code was then reimbursed. This got us close to break even for a level one visit. Unbeknownst to us the CPT code 31270-52 for a NP aspirate was our savior that allowed us to continue providing the best patient experience, the best sensitivity test, and profitability.
I will digress and talk about the quality of COVID-19 testing and how this now applies to reimbursement. Payment for quality is not new to any of us. Unfortunately, coronavirus has turned our viral testing into an assembly line without regard to maintaining quality, results, and sensitivities as the main prerogative. The test is only as good as the specimen collected which thereby affects the sensitivities. Who wants to put a patient through the test telling them they don’t have COVID-19 when they actually do? NP swab testing is being done incorrectly by too many test takers, clinics, and hospitals. You only have to watch the local newscast story to see the swab extending along the nasal dorsum or extending half the length of the swab. Poor specimen collection results in poor sensitivities!
Historically, the best specimen collection demonstrating the highest sensitivities for ALL viruses has been nasopharyngeal aspiration. For those that have personally experienced a NP swab vs a properly performed NP aspirate, the NP aspirate is hands down less time and less uncomfortable from a patient perspective. For those nay-sayers out there who have not been on the receiving end of both, I encourage you to experience both so you can personally share this with your patients.
Now getting back to reimbursement…NP aspirate can be the win-win for patients/hospitals/clinics. For patients it is less uncomfortable than a properly performed NP swab and certainly less than an improperly performed NP swab. More importantly NP aspirate gives the highest sensitivities thereby the patient subjected to a COVID-19 test may feel confident that it is the most accurate of all specimen collection methods. The bonus for the clinics/hospitals performing this sample technique is that is reimbursable using CPT code 31270-52. Our average reimbursement in the clinic is around $120 for our commercial based insurers and it has been covered by all carriers…as it should based on the CARES Act. With use of NP aspiration, such as N-Pak, this allows the clinic and hospital reimbursement beyond break even to do the right thing for your patient. Allowing reimbursement is very important in these times of COVID-19. This is not “gouging” the system but rather allowing proper reimbursement for proper testing for your patient.
Getting properly reimbursed for testing with an office visit and specimen collection is not without its downsides. This requires a room and NP aspirates MUST be performed with the patient in a supine position and neck extended to allow pooling in the nasopharynx thereby obtaining the greatest viral load. This is NOT a drive-thru technique. But attention to patient comfort, experience and ultimately RESULTS should be our focus. Use of NP aspiration for COVID-19 testing can get you proper reimbursement for your expertise and understanding of this!