Concern over unexpected bills was one of the reasons given by survey respondents for hesitation about getting the shot.Overlooking the Washington Monument, encouragement to get vaccinated. Jacquelyn Martin/Associated PressWhen Paul Moser considers getting a coronavirus vaccine, he also thinks about his outstanding medical debt: $1,200 from a few urology visits that he has been unable to pay off.Mr. Moser, a 52-year-old gas station cashier in New York State, has friends who were surprised by bills for coronavirus tests, and worries the same could happen with the vaccine. For now, he’s holding off on getting his shot.“We were told by the legislators that all the testing was supposed to be free, and then surprise, it’s $150,” he said. “I agree it’s important to get vaccinated, but I don’t have a sense of urgency around it.”Congress passed laws barring pharmacies and hospitals from billing patients for coronavirus vaccines. Signs at vaccination sites advertise that the shot is free. From the beginning, health officials and government leaders have told the public it won’t cost anything. And there have been few reports of people experiencing charges.Even so, some unvaccinated adults cite concerns about a surprise bill as a reason for not getting the shot. Many of them are accustomed to a health system in which the bills are frequent, large and often unexpected.A recent Kaiser Family Foundation poll found that about a third of unvaccinated adults were unsure whether insurance covered the new vaccine and were concerned they might need to pay for the shot. The concern was especially pronounced among Hispanic and Black survey respondents.“The conversations we have are like: ‘Yes, I know it’s good. Yes, I want it, but I don’t have insurance,’” said Ilan Shapiro, medical director of AltaMed, a community health network in Southern California that serves a large Hispanic population. “We’re trying to make sure everyone knows it’s free.”The confusion may represent a lack of information, or skepticism that a bill won’t follow a visit to the doctor. Liz Hamel, director of survey research at Kaiser, said it could reflect people’s experience with the health system: “People may have heard it’s available for free, but not believe it.”Congress has tried to protect patients from bills for coronavirus vaccines and tests. Early in the pandemic, it mandated that insurers waive co-payments and deductibles for both services, and set up a fund to reimburse doctors seeing uninsured patients.Even so, patients found themselves facing bills for testing — some for over $1,000. Some doctors billed uninsured patients for tests rather than the new, federal fund. Others tacked on unexpected fees and services to the testing visit.The rules for vaccine billing were made even stricter. To become vaccinators, doctors and pharmacies had to sign a contract promising not to bill patients for shots.The stronger protections appear to have worked. While many patients have encountered coronavirus bills for testing — The New York Times has documented dozens of cases in bills submitted by readers — there have been only a handful involving vaccines.Still, some unexpected charges have slipped through: Patients in Illinois, North Carolina and Colorado have mistakenly received vaccine bills. In all cases, vaccine providers reversed the charge and apologized for the errors.The federal government has received some complaints about unexpected charges, and recently warned doctors against billing patients.Surprise bills for coronavirus vaccines, tests and other medical care can leave an impression on patients. Americans with medical debt are more likely to skip needed care than people who hold other types of debt, like outstanding credit card bills or student loans, according to a 2013 study by Lucie Kalousova, an assistant professor of sociology at the University of California, Riverside.“For someone who has incurred medical debt, they may be told by the media and everyone else that the vaccine is cost-free, but they’ve also had this very negative, prior encounter with the medical system that has created feelings of mistrust,” she said.Some patients who worried about the cost of a coronavirus vaccine said they always expect a bill to follow a doctor’s appointment. They cited stories from friends or family members who ended up with expensive coronavirus testing and treatment bills, and wondered why the vaccine would be any different.“This is America — your health care is not free,” said Elizabeth Drummond, a 42-year-old mother in Oregon who is unvaccinated. “I just feel like that is how the vaccination process is going to go. They’re going to try to capitalize on it.”It’s also possible that survey research overstates how many Americans fear getting a surprise vaccine bill. When The Times, through Kaiser’s help, conducted follow-up interviews, some poll respondents who voiced this concern said it didn’t actually matter much to them.Instead, they said they responded that way to express frustration with the vaccine or the wider American health system.“The cost is the smallest detail,” said Cody Sirman, a 32-year-old who works in manufacturing in Texas and who has decided to go unvaccinated. He said he wouldn’t mind paying for the vaccine if he trusted it — but he doesn’t: “I think the vaccine is a complete sham. It was just a way to see how much control the government can have over the population.”A public bus turned mobile vaccination clinic in Foley, Minn., this month. Health officials are finding inventive ways to make getting a shot simpler, yet it’s clear that some reluctance is a result of other factors.Liam James Doyle for The New York TimesFor many, the potential cost of a vaccine is only part of a constellation of reasons for remaining unvaccinated. It can often be hard for pollsters to know — or even patients to identify — the decisive factor. Separate research from the Census Bureau last month found that Americans were more worried about vaccine side effects than about potential charges.“Most people aren’t saying they’re just concerned about one thing; it’s usually a lot of things,” said Ms. Hamel of the Kaiser Family Foundation.Tiffany Addotey, a 42-year-old school bus driver in North Carolina, does cite a concern about cost. That stems mostly from her experience trying to get a coronavirus test.“It concerns me that some places were charging like $200 for coronavirus tests,” she said. “I didn’t pay. I went home. I have enough bills as it is.”There are other things that concern her, like the safety of the vaccine given its fast development, as well as the recent Johnson & Johnson vaccine pause.When Ms. Addotey was informed that federal law makes the vaccine free for all Americans, she responded, “So I’ll just have to pay my co-pay?”Learning that it really would be free, with no co-payment, “helped a little bit,” she said. But it wasn’t enough to put her mind at ease about getting vaccinated, at least not yet.“I’m going to try and wait for it to be on the market a little longer,” she said. “I feel like I will get it, after a little more research and a little more time.”

One coronavirus survivor manages her medical bills in color-coded folders: green, red and tan for different types of documents. A man whose father died of the virus last fall uses an Excel spreadsheet to organize the outstanding debts. It has 457 rows, one for each of his father’s bills, totaling over $1 million.These are people who are facing the financial version of long-haul Covid: They’ve found their lives and finances upended by medical bills resulting from a bout with the virus.Their desks and coffee tables have stacks of billing documents. They are fluent in the jargon of coronavirus medical coding, after hundreds of hours of phone calls discussing the charges with hospitals, doctors and insurers.“People think there is some relief program for medical bills for coronavirus patients,” said Jennifer Miller, a psychologist near Milwaukee who is working with a lawyer to challenge thousands in outstanding debt from two emergency room visits last year. “It just doesn’t exist.”Americans with other serious illnesses regularly face exorbitant and confusing bills after treatment, but things were supposed to be different for coronavirus patients. Many large health plans wrote special rules, waiving co-payments and deductibles for coronavirus hospitalizations. When doctors and hospitals accepted bailout funds, Congress barred them from “balance-billing” patients — the practice of seeking additional payment beyond what the insurer has paid.Interviews with more than a dozen patients suggest those efforts have fallen short. Some with private insurance are bearing the costs of their coronavirus treatments, and the bills can stretch into the tens of thousands of dollars.“There are things I’ve researched, and known I should do, but I have a fear of being blindsided by the bills,” said Lauren Lueder, a 33-year-old teacher who lives in Detroit. She has depleted $7,000 in savings to pay for treatment so far. “You end up with a battery of tests, and every single thing adds up. I don’t have the disposable income to constantly pay for that.”For 10 months, The New York Times has tracked the high costs of coronavirus testing and treatment through a crowdsourced database that includes more than 800 medical bills submitted by readers. If you have a bill to submit, you can do so here.Those bills show that some hospitals are not complying with the ban on balance billing. Some are incorrectly coding visits, meaning the special coronavirus protections that insurers put in place are not applied. Others are going after debts of patients who died from the virus, pursuing estates that would otherwise go to family members.Hospitals and insurers say that they have tried to adapt to the different billing guidance for the pandemic, but that confusion can arise when new charge codes are created and new rules set up quickly.Coronavirus patients face significant direct costs: the money pulled out of savings and retirement accounts to pay doctors and hospitals. Many are also struggling with indirect costs, like the hours spent calling providers and insurers to sort out what is actually owed, and the mental strain of worrying about how to pay.Ms. Miller, like many other patients, described trying to sort out her complicated medical charges — in her case in color-coded folders — while also battling the mental “brain fog” that affects as many as half of coronavirus long-haul patients.“I have a Ph.D., but this is beyond my abilities,” she said. “I haven’t even begun to look at my 2021 bills because we’re still dealing with 2020 bills. When the bills come nonstop, you can only deal with so much.”The United States is estimated to have spent over $30 billion on coronavirus hospitalizations since the pandemic began, according to Chris Sloan, a principal at the health research firm Avalere. The average cost of each hospital stay is $23,489. Little research has been published on how much of that cost is billed to patients. “The government is focused on getting the vaccine out, but it doesn’t look like there is anyone out there thinking more about the long-term impacts on the people experiencing unusually high costs from Covid,” said Nancy-Ann DeParle, a former Obama administration health policy adviser and co-chair of the Covid Patient Recovery Alliance, a new nonprofit that plans to study the issue.Patients who have tried to take advantage of their insurers’ cost waivers are sometimes finding themselves thwarted by hospitals and providers that don’t code their bills as related to coronavirus. Without the right coding, the patients’ normal deductibles and co-payments apply.One coronavirus patient in Chicago recounted spending 50 hours trying to get the coding for an M.R.I. scan changed, to show it was related to coronavirus. His insurer will pay the entire bill if that happens — but if not, he is responsible for $1,600. So far, the issue is still unresolved.Senator Tina Smith of Minnesota, the lead sponsor of a bill to make coronavirus care free.Jason Andrew for The New York Times“I’ve heard so many stories of people being completely stymied filling out reimbursement forms and trying to get insurance to cover them,” said Senator Tina Smith, Democrat of Minnesota, the lead sponsor of a bill to make coronavirus care free. “It’s almost as if the system is designed to make it hard to get reimbursed.”Congress mandated that insurers make coronavirus testing free last spring, but never wrote a similar requirement for treatment coverage — in part because insurers were volunteering to waive patient costs, she said.Insurers are now starting to wind down those special protections: Aetna, Anthem and UnitedHealthcare — three of the country’s largest health plans — have ended some portion of their waivers this year. They have decided to treat the virus the same as the many other diseases that send patients to doctors’ offices and hospitals.Some emphasized they are now focused on ensuring patients get Covid vaccines without facing any costs.“There was a feeling that many private plans were initially covering treatment, but now that is petering out and leaving people on the hook,” Senator Smith said.Some Covid financial long-haulers never became ill themselves, but are overwhelmed by the bills that deceased loved ones left behind.Rebecca Gale, 64, lost her husband of 25 years, Michael, to coronavirus last summer. Their insurance fully covered most of the “big stack” of medical bills that Ms. Gale received after his death. But it paid only a small portion of the $50,009 air ambulance bill for Mr. Gale’s transport between hospitals when his condition was deteriorating.“I cry every day; this is just another thing that breaks my heart, that on top of losing my husband I have to deal with this,” Ms. Gale said.The family’s health insurance plan limits its coverage of air ambulances to $10,000, and the air ambulance company spent months pursuing an additional $40,009 from Mr. Gale’s estate. Ms. Gale retired last year, from a job at an Ohio automotive factory stamping car parts, anticipating she would get to spend more time with her husband. After he died and the bills started to show up, she considered looking for a part-time job to help pay the charges.Health care companies have discretion over what to do about the debts of deceased patients, sometimes pursuing their estates for reimbursement.The air ambulance company, PHI Medical, declined to comment on Mr. Gale’s bill but said in a statement that it “followed the regulatory requirements” for billing coronavirus patients. It did cancel the charges, however, after The Times inquired about the bill.Shubham Chandra left a well-paying job at a New York City start-up partly to manage the hundreds of medical bills resulting from his father’s seven-month hospitalization. His father, a cardiologist, died from coronavirus last fall.For months he has spent 10 to 20 hours a week working through the charges, using his mornings for reading through new bills, and his afternoons for calls to insurers and hospitals. His spreadsheet recently showed 97 bills rejected by insurance with a potential of over $400,000 the family could owe. Mr. Chandra tells providers that his father is no longer alive, but the bills continue to accumulate.“A large part of my life is thinking about these bills,” he said. “It can become an impediment to my day-to-day. It’s hard to sleep when you have hundreds of thousands of dollars in outstanding debts.”Some coronavirus patients are postponing additional medical care for long-term side effects until they can resolve their existing debts. They are finding that long-haul coronavirus often requires visits to multiple specialists and many scans to resolve lingering symptoms, but they worry about piling up more debt.Irena Schulz, 61, a retired biologist who lives in South Carolina, became ill with coronavirus last summer. She has multiple lingering side effects, including problems with her hearing and her kidneys. She recently received a $5,400 bill for hearing aids (to help with coronavirus-related hearing loss) that she had expected her health insurance to cover.She has eschewed trips to the emergency room when feeling ill because she worries about the costs. She’s managing her kidney-related pain by herself, at home, until she feels she can afford to see a specialist.“I keep on with Tylenol and drinking a lot of water, and I’ve noticed it does help if I drink a lot of pineapple juice,” she said. “If the pain gets past a certain threshold, I’ll see a doctor. We’re retired, we’re on a fixed income, and there are only so many things you can accumulate on the credit card.”

Insurers are stuck with the big bills from Lenox Hill, but the public ultimately pays through higher premiums.The Lenox Hill Greenwich Village emergency department, where patients have been charged extraordinarily high prices for coronavirus tests. This photo was taken in mid-March; the blue parts of the signs advertising Covid testing have since been removed.Steven Molina Contreras for The New York TimesLenox Hill Hospital in Manhattan advertised its “Covid-19 Testing” on a large blue and white banner outside its Greenwich Village division’s emergency room. The banner said nothing about cost.But cost turned out to be the testing’s most noteworthy feature. Lenox Hill, one of the city’s oldest and best-known hospitals, repeatedly billed patients more than $3,000 for the routine nasal swab test, about 30 times the test’s typical cost.“It was shocking to see a number like that, when I’ve gotten tested before for about $135,” said Ana Roa, who was billed $3,358 for a test at Lenox Hill last month.Ms. Roa’s coronavirus test bill is among 16 that The New York Times reviewed from the site. They show that Lenox Hill arrives at its unusually high prices by charging a large fee for the test itself — about six times the typical charge — and by billing the encounter as a “moderately complex” emergency room visit. In one case, a family accrued $39,314 in charges for 12 tests this winter, all taken to fulfill requirements for returning to work or school. In another, an asymptomatic patient walked in because she saw the banner outside and wanted a test after traveling. Her insurance was charged $2,963.Federal legislation last year mandated that coronavirus testing be free for patients, so individuals are typically protected. None of the patients tested at the Lenox Hill emergency room were billed directly for the service. But eventually, American patients bear the costs of these expensive tests in the form of higher insurance premiums.Patient bills show that at least one additional hospital owned by Lenox Hill’s parent group, Northwell Health, has charged emergency room fees to patients at a mass testing site.“It felt like deception, and an effort to try and get money that they are not entitled to,” said Ute Tabi. She was reviewing her family’s insurance claims and saw a $2,793 charge for a drive-through coronavirus test her husband got at a Northwell hospital in the New York suburbs, Huntington Hospital on Long Island. The hospital pursued the family for a share of the bill, which Ms. Tabi has so far refused to pay. The Times has been asking readers to submit bills so that we can understand the costs of coronavirus testing and treatment. So far, more than 600 patients have participated. Their bills have revealed high charges and illegal fees, as well as patients who face substantial medical debt for coronavirus treatment. If you have a bill for coronavirus testing or treatment, you can share it here.Northwell Health, a nonprofit, operates 23 hospitals in the region, and received about $1.2 billion in emergency health provider funding in the federal CARES Act last year.The chain recently came under scrutiny after The Times revealed it had sued more than 2,500 patients for medical debt during the pandemic. It has since dropped those cases.Northwell, which defended its coronavirus testing charges as appropriate, has since removed the blue signs at the Greenwich Village division advertising the service.Officials said patients tested at the emergency room received more advanced care than they would elsewhere. They declined to comment on specific patient cases but said their protocols involve notifying patients that their test will come with emergency room fees. A sign with the information is taped to a plexiglass shield at the registration desk.“I don’t think of the emergency room as a testing site,” said Barbara Osborn, Northwell’s vice president for communications.But the Lenox Hill in Greenwich Village has tested 15,000 patients for coronavirus over the course of the pandemic. Patients interviewed by The Times said they went there because of the banner outside, not to seek emergency care. They were asymptomatic and seeking tests as a precaution before traveling or socializing.Ms. Roa spotted the emergency room fee through an unusual circumstance. Her wallet had been stolen, and she was checking her bills. She feared her identity had been stolen because she had no memory of visiting an emergency room.“I called my insurance and was freaking out, asking who has my identity, what will this bring,” she said. “After maybe 45 minutes, I got transferred to someone who was able to tell me that this was all about a Covid test.”Congress inadvertently encourages expensive testsAmericans have taken about 370 million tests during the pandemic. The price of each — as with most services in the American health system — can vary widely from one hospital or doctor’s office to another.State-run testing sites in New York do not charge patients or collect health insurance information for the Covid nasal swab tests. A study published last year found that a swab test at a hospital can run from $20 to $850. Some independent laboratories have charged more, billing $2,315.The Lenox Hill Greenwich Village center bills $671 for its coronavirus test, six times what major labs such as LabCorp and Quest charge. The rest of the price discrepancy comes from the emergency room fees.Doctors and hospitals that bill higher prices for testing can rely on new federal protections to ensure they are paid. Congress passed a law last year that requires insurers to fully cover coronavirus testing costs and not apply any patient co-payments or other fees to the service.Insurers must also pay for services that are necessary to obtain the coronavirus test, such as a doctor’s visit or, in the case of Lenox Hill, an emergency room facility fee.“This is such a gold mine for hospitals because now they can charge emergency fees for completely healthy people that just want to be tested,” said Renee Hsia, a professor of emergency medicine at the University of California, San Francisco, who researches medical billing. “This is what you’d expect from a market-oriented approach to health care. It’s the behavior our laws have incentivized.”Emergency rooms in the United States typically charge patients something called a facility fee, the price of walking through the door and seeking care. The fees have risen sharply in recent years, and can cost about $200 for a simple visit or $1,800 for the most complex cases.Hospitals like Lenox Hill often defend these costs as necessary to fulfill federal laws that require them care for all patients regardless of their ability to pay.“If someone does not have insurance, we still provide the same level of care as we would to someone who has insurance,” said Rich Miller, Northwell’s chief business officer.Emergency room fees are common in the American system but rare in the world of coronavirus testing. At The Times’s request, the data firm Castlight Health analyzed insurance claims for 1.5 million coronavirus tests.It found that less than 4 percent of coronavirus tests are billed through emergency departments. The vast majority of those tests are associated with large claims that have many charges, suggesting the nasal swab was incidental to a more complex visit.Only about 5,000 bills out of the sample of 1.5 million — about 0.3 percent — were billed in a way that looked similar to Lenox Hill’s fees, the Castlight data shows.At the Lenox Hill site, Mr. Miller explained, there are actually two separate coronavirus testing processes. Patients who arrive with a doctor’s order for a coronavirus test are routed to a service center that does not charge emergency room fees.Patients who come in without that prescription are sent to the emergency room for an evaluation, where they will incur the facility fee charges. About 75 percent of coronavirus tests at Lenox Hill Greenwich Village are routed through the emergency room, a practice Mr. Miller defended.“Anyone who would have been billed for an emergency room visit would have been assessed accordingly to see if other things were wrong with them,” Mr. Miller said. “We believe we’re adequately disclosing that this is an emergency department visit, and will be billed as E.R.”Short visits, surprising billsFounded in 1857, Lenox Hill has long served a wealthy clientele at its main division on the Upper East Side of Manhattan. It is where Beyoncé gave birth in 2012, and is the subject of an eponymous Netflix documentary series that shows the hospital’s inner workings.In 2010, New York State awarded Lenox Hill the rights to take over the Greenwich Village building left empty by the closing of St. Vincent’s Hospital. It replaced it with a free-standing emergency room.It would stay open 24 hours and provide care to patients regardless of their ability to pay. But unlike traditional emergency rooms, it is not physically attached to a larger hospital.Free-standing emergency rooms have proliferated in recent years, across the country and across New York City. Montefiore, Northwell and N.Y.U.-Langone have all opened them within the last decade.Supporters have praised them for expanding critical care access without building an entire hospital, a potential boon to underserved urban and rural areas.But they have also faced criticism for how they price care, especially for simple visits. One analysis conducted by the health insurer UnitedHealthcare found that the average cost for a visit related to a common condition like a fever or cough was 19 times higher in free-standing emergency rooms than in urgent care centers.“Free-standing emergency departments simultaneously represent the best, innovative side of American health care and the pure profit motive,” said Dr. Jeremiah Schuur, chair of the emergency medicine department at Brown University’s Alpert Medical School.The prices at Lenox Hill’s free-standing emergency room caught the eye of local government officials shortly after it opened. New York City’s Community Board 2, which has jurisdiction over Greenwich Village, held a meeting in 2016 to discuss several cases. One patient was charged $1,000 to have a bee sting looked at, and another faced fees of $3,000 related to a sprained ankle.Sarah Nathan was not looking for emergency-level care when she was tested at Lenox Hill Greenwich Village. She just needed a test to return to her job as a nursery school teacher.The bill for her visit came to $3,194, which her insurance negotiated down to $2,084. She recalls asking a front desk representative whether she would be billed for an emergency room visit. She said she was told she would not be.Ms. Nathan worries about the impact these high fees could have on her premiums.“My insurance is so expensive already, and it infuriates me that they’re adding to the cost of that for New Yorkers,” she said.Coronavirus tests were scarce at the start of the pandemic, but have since become plentiful, raising questions about why Lenox Hill advertised testing at this site.Northwell owns an urgent care center that is a 15-minute walk from the Lenox Hill emergency room. The urgent care center’s charge for a Covid nasal swab test and doctor visit usually comes to $350 — nearly 90 percent less.