LIMA — When I logged into my electronic health record securely using MyChart, I noticed a new charge, one I never expected—a bill for my two COVID vaccine inoculations.

Mercy Health’s Lima IMM Clinic sits adjacent to its hospital. Beginning in January 2021 its sole purpose became vaccine distribution for residents of Lima and surrounding areas. I received an invitation to get my vaccine there through MyChart because my family physician is affiliated with Mercy Health.

I arrived for my first scheduled vaccine appointment. For good measure, I also brought along a family member who needed their vaccine. Along the left side of the room stretched a single row of tables. In front of each chair, a line of consent forms lay evenly spaced and perpendicular, like little coffins. I wondered if others prompted to visit this place today with me were also thinking of loved ones who were hospitalized and nearly died, or died, from COVID-19.

I took a spot, hunched over and scrupulously examined my form. The form asked about my previous medical history and health conditions. And, of course, it requested my consent for the experimental Pfizer vaccine I would be receiving.

Given the fact everyone has a slight biological uniqueness, I suddenly found myself nervous that the vaccine might not be safe and or have long-term side effects for me. I’d been dreading the vaccine for this reason. I reassured myself that the millions of people who had received the vaccine before me were already a larger cohort of adult test subjects than any standard clinical trial.

After checking several boxes and applying my John Hancock, I slipped it to the hands of a woman monitoring the table. She glided me into another room.

I found myself standing next to a registration and intake station. That’s the desk (in this case, a makeshift folding table) where the provider collects patient names, birthdates, proof of identity such as a driver’s license—and insurance information. For those with medical coverage, providers may send claims to the patient’s insurance company. While some insurers have been ending their waivers for COVID-19 treatment, federal law still prohibits medical insurance companies from charging insured individuals deductibles for their vaccination.

Someone welcomed me and located my file in the MyChart system, and I was approved to move forward. I looked around at this gathering of masked, morose individuals, scared of one other as potential spreaders of this contagion, who were hoping for a better line of defense thanks to the modern wonders of science. This strange assembly line was progressing toward protection as though we were mimicking the body’s genetic factory system itself, mRNA, harnessed to create this vaccine. Was I an A, U, G, or C in this menagerie?

Following the registration process, I was directed to one of several inoculation stations. The jab was quick and painless. I had no complaints. A Band-Aid was applied and the pharmacist administering my vaccine scheduled my next shot. She then directed me to a waiting area with rows of chairs filled with fellow “innoculees,” where staff hovered around the edges of the room monitoring us. Hesitant to sit next to others, or those who might violate the 6-foot social distancing rule by crossing in front of me to reach their seat, my relative and I decided to be the oddballs by locating ourselves away from the chairs. After waiting the requisite 15 minutes we departed and then returned to repeat the entire process several weeks later.

By Aug. 17, Mercy Health distributed nearly 16,000 vaccines in the Lima area, like the two I received.

Several months passed. I was protected, free of charge, against the SARS-CoV-2 virus — or so I thought. In late July, I noticed a bill in MyChart stating I had an outstanding balance, and when I examined the details, there was a nominal charge for the vaccine but a substantial one for the administrative fees charged by the pharmacist delivering them.

As a working professional who did a great job (presumably with a smile behind her mask), the pharmacist certainly deserves to be paid—but in these special circumstances, not by me.

During Operation Warp Speed, President Trump pledged that once the Food and Drug Administration provided emergency use authorization of Pfizer’s vaccine, the U.S. government would buy $1.95 billion worth for public distribution. Moreover, multiple pieces of federal legislation guaranteed uninsured individuals living in the US would be fully covered for the vaccine and vaccine administration fees. Even though the website for the Centers for Disease Control (CDC) explicitly states “providers cannot charge the vaccine recipient the balance of the bill,” Mercy Health’s cost for both doses after their “uninsured discount” adds up to just over $50, which patients were billed.

While it is unclear how many COVID-19 vaccine recipients have been billed through the Mercy Health system, the problem appears to be a confusion about where providers and external medical billing companies should submit their claims for the uninsured. Given the legislation, providers and billing companies may face legal consequences if they engage in widespread direct charging of vaccine administration fees through COVID-19 vaccine distribution clinics.

According to the U.S. Department of Health and Human Services (HHS) website, the CARES Act legally prohibits providers participating in the U.S. Health Resources and Services Administration (HRSA) COVID-19 Uninsured Program from charging a patient directly for vaccine administration fees, or any other fees, if the vaccine was the “sole medical purpose provided,” such as a visit to a COVID-19 vaccine clinic. What may not be immediately clear is that provider participation is not optional. Any provider who received doses of the vaccine, must register, and provide any uninsured patient’s information to prevent them from paying out-of-pocket costs. The HHS website states, “providers participating in the CDC COVID-19 Vaccination Program (which currently includes any provider administering COVID-19 vaccine) still cannot charge you, regardless of insurance status, for the COVID-19 vaccine or administration of the COVID-19 vaccine.”

The idea is that price should not be a deterrent preventing individuals, insured or uninsured, from getting their vaccine.

“We want to dispel the fact that finances would get in the way of this,” said Erica Blake, Media Relations Manager for the Great Lakes Group of Mercy Health, when referring to the national COVID-19 vaccine effort. But by the time this story went to press, I was unable to get any answers as to whether Mercy Health (and/or its individual vaccine providers) registered with the federal uninsured program.

So, it is unclear why all providers were not simply mandated by HHS to register with the uninsured program and participate in a brief video tutorial before being eligible to receive their first shipment of vaccine doses. Instead, HHS contracted with United Heathcare to work with COVID-19 vaccine providers around the country after doses were delivered to uninsured individuals.

According to United Healthcare representative Jeff P., at first told me I could be billed administration fees. But after asking Jeff to speak to a supervisor, he returned saying vaccine provider(s) are required to register with the HRSA’s COVID-19 Uninsured Program and submit all its uninsured claims so that its uninsured patients are not billed directly. He also confirmed the uninsured program is free and currently open to new registrants and gives full reimbursement to providers for uninsured vaccine administration fees.

Unless my case was an isolated one, the scope of the problem could be far-reaching. This is because Bon Secours Mercy Health operates 50 hospitals in the U.S. and Ireland. They outsource their U.S. billing to Ensemble Health Partners of Blue Ash, Ohio (ensemblehp.com), which is a national billing company.

According to a customer service representative, Ensemble has several policies in place to ensure we appropriately meet all federal and state guidelines.

In medical billing, each charge is assigned a specific number, and in the case of the charges I was billed, those numbers are 0002A ($42) and 91300 ($0.01). As a medical billing company and aware of the global pandemic, and the provider sending their bills to Ensemble should be aware of the CDC’s protocols regarding the free vaccine mandate.

According to Ensemble, Bohle was not charged for the vaccine. Her account has been reviewed. When Ms. Bohle contacted BSMH customer service to inquire about her vaccine accounts, the accounts had already been flagged, which is why she was not billed.

Erica, an Ensemble representative told me that the last she heard, it has been going to the patients just for the administrating fee.

When speaking to Michael, an Ensemble customer service manager, told me he did not know if the free vaccine also included the administrative fee. (It does). I asked him to conduct such a search to let me know how many patients were being directly billed the administrative fee. He stated he did not know if it was possible to do a system-wide search by medical billing code numbers. At the end of the call, he explained that he could only look up information on a patient-by-patient basis.

According to Ensemble, it is routine for an administrative fee to be billed separately. As referenced in Ensemble’s original statemen, it is against Ensemble policy, and its ethical code of contact, to disclose billing information.

Therefore, on Monday, Aug. 16, I emailed Ensemble’s Founder and CEO, Judson Ivy, and called him the morning of Aug. 18 leaving him a voicemail requesting a news interview and the number of uninsured COVID-19 vaccine recipients who were directly billed administrative fees through their system. Kendall Herold, Public Relations manager, replied instead. Her email stated Ivy is unavailable for an interview and asked to know more about the article. In the end, Herold declined a phone interview but issued the following statement:

“It is against Ensemble policy to disclose billing information. Billing varies by state and provider policies specific to each individual health system. We are dedicated to supporting our clients, and the patients they serve, as they continue to navigate the COVID-19 pandemic through compliant and appropriate billing guidelines. The work we do allows our healthcare provider partners to focus on what they do best — delivering exceptional care to their patients and communities.”

Her answer should have been zero.

By end of day on Aug. 18, my bill was reduced to $0.02 for the vaccine.

If, like me, you see charges applied for your vaccine, talk to your provider before paying to see if they will cancel the bill. For those who have already paid, discuss a refund.

But if these steps prove unsuccessful, HHS recommends filing a complaint with their Office of Inspector General by calling 800-HHS-TIPS or online at https://TIPS.HHS.GOV.

Vaccine providers can enroll in the federal program for uninsured claims reimbursement at https://www.hrsa.gov/coviduninsuredclaim.

For more information about the national COVID-19 vaccination billing policy, visit https://www.cdc.gov/coronavirus/2019-ncov/vaccines/no-cost.html.