When Mara Varona was pregnant she decided to take a common prenatal blood test to screen for genetic conditions. It was part of a proactive approach she and her husband took to pregnancy.
"We're just information people," says Varona, who works in finance and lives in Miami, Florida. "We'd rather have as much information as we can."
Pay $349 now or ...
Shortly after her blood draw, the testing company Natera emailed and texted her an offer to pay its cash price — $349 and skip insurance altogether. The offers said she was out of network and estimated Varona's cost would be the balance of her deductible plus $100 to $200, according to a statement from Natera.
But Varona doesn't recall seeing the offers at the time they were sent. She found them in her records as NPR was reporting this story. The email and text required her to click through to see the details. She let the bill go to her insurance assuming it would pick up most of the tab.
The blood test results came back with good news — no signs of genetic concerns.
But a few months later, other news arrived: a bill for $750, the amount of her unmet insurance deductible. According to the explanation of benefits, Natera had charged her insurance company $4,480. The insurer paid just 45 cents.
"I tend to be the type to just pay it and move on," she says. "But something in me told me this just seemed unreasonably high. It was probably the highest medical bill I'd received throughout the pregnancy."
Varona tried calling both Natera and her insurer to understand the charge, but didn't get clarity. She put the bill aside until shortly after she gave birth. That's when she received a notice that if she didn't pay the bill it would go to collections.
"I wanted to take care of it," she says.
Then she came across a Reddit thread. Other women were sharing a tip: Call Natera and ask to pay the cash rate instead of going through insurance.
A counterintuitive trend
While Varona's experience might sound unusual it's not. In fact, it reflects a reality of the U.S. health care system: Paying the out-of-pocket cash price can sometimes be cheaper than using health insurance.
This dynamic became more visible in 2021, when a new federal rule required hospitals to publish their prices online. Since then, researchers have found that for a wide range of services—like lab tests, X-rays, and even joint replacements—many hospitals charge cash-paying patients less than they charge insured ones.
A study published in JAMA Network Open in 2021 found that for half of the hospitals surveyed, cash prices were lower than the median price negotiated by insurance companies.
Ge Bai, a professor of health policy and management at Johns Hopkins University and co-author of the study, said she became interested in the topic after her own experience. She discovered that using her insurance for a blood test for her son would have cost three times more than paying in cash.
"We always believe insurance companies exist to use their bargaining power to get better prices," Bai says. "But this ruined my faith in that idea."
Bai says there are a few reasons for this price mismatch. One is administrative — providers are more willing to offer a discount when they don't have to deal with insurance paperwork and delayed payments. Another is market behavior: Consumers paying cash are more likely to shop around for the best price.
There's also a profit motive at play for insurers. Insurers are allowed to keep up to 20 percent of the premiums they collect for administrative costs and profit.
That means lower medical spending can actually reduce an insurer's revenue.
And that's why, Bai says, insurance companies cannot be relied upon to get us the lowest prices.
"Proactive approach"
NPR contacted Varona's insurer, Independence Blue Cross, which confirmed she is a member and has access to Florida Blue's network where she lives. Both insurers declined to answer questions about her case and explain why they only reimbursed 45 cents for her test.
NPR also asked Natera about its pricing policies.
"We recognize that health insurance can be difficult to navigate, and we provide patients with clear, upfront information about coverage and cost," Brian Symmons, Natera's senior vice president of patient experience wrote in a statement. "We provide cost estimates before billing insurance whenever possible. If Natera is out-of network with a patient's insurer, or if our estimate shows their cost would likely exceed the cash price, we notify them and offer the option to pay the lower rate instead. Natera was one of the first in the industry to adopt this proactive approach."
Natera did not answer NPR's questions about how often it provides cost estimates for patients, but said the company needs valid contact info for patients to send the estimates.
A phone call that saved $400
Varona tested out the theory she read on Reddit about calling Natera and asking for what's described on the company's website as a "prompt-pay cash price." To her surprise, it worked.
"I thought it was b******t that they can just suddenly come up with another amount," she said. "But I was also happy I just saved $400."
In the statement, Symmons writes that "Before billing, we contacted her by email and text, explained our out-of-network status, estimated her cost would likely fall between $100–$200 after her deductible was met." That sum turned out to be $750, which was her unmet deductible. "In conversations with our team, Ms. Varona expressed confusion about her insurance benefits, and we therefore made a courtesy adjustment."
Varona said her experience paying the cheaper cash rate has completely changed how she approaches medical bills.
"I question the bills now," she said. "I don't just pay them right away."
A high insurance price and lawsuits
Part of the problem for consumers is the list price for insurers. In Varona's situation, that was Natera's $4,480 price. With a price that high, anyone in a high deductible plan using their insurance could easily owe their full deductible on one out-of-network blood test — hundreds of dollars, as in Varona's case, or even thousands. Natera did not answer NPR's question asking why it sets this list price at more than 10 times what it was willing to accept as a cash payment in Varona's case. Symmons said in a statement that Natera offers the rate to patients with high deductibles or the uninsured but it's not the primary way the company gets paid for these tests.
The company is facing some legal challenges for its billing practices.
One patient who paid more than $1,000 for these tests with insurance is part of a proposed class action lawsuit against Natera. The suit was filed in December 2023 in California. An earlier proposed class action suit alleging that the company was deceptive about its pricing was dismissed in 2023. That's because the female plaintiff never ended up paying the full medical bill she alleged was hundreds of dollars more than the bill of up to $249 she had anticipated. In dismissing that lawsuit, the judge noted that the public-facing statements Natera provided to patients said "some patients will in fact pay more than $250 for a genetic test."
Natera's spokesperson Symmons wrote in a statement, "We strongly deny the allegations in the pending lawsuit. Our billing policies reflect our focus on transparency, patient choice, and affordability."
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