Reesha Ahmed was on cloud nine.

It was January and Ahmed was at an OB-GYN's office near her home in Venus, Texas, for her first prenatal checkup. After an ultrasound, getting anti-nausea medication, and discussing her pregnancy care plan, she said, a nurse made a convenient suggestion: Head to the lab just down the hall for a standard panel of tests.

The lab was inside Texas Health Hospital Mansfield, which opened in December 2020 in a Dallas-Fort Worth suburb. Ahmed, just eight weeks pregnant, said the doctor told her everything about the visit was routine. "Nothing really stood out," Ahmed said. "And, of course, there's just a lot of excitement, and so I really didn't think twice about anything."

Her blood tests checked for multiple sexually transmitted infections, her blood type, and various hormones. Within days, Ahmed began bleeding and her excitement turned to fear. A repeat ultrasound in early February showed no fetus.

"My heart kind of fell apart at that moment because I knew exactly what that meant," she said.

She would have a miscarriage.

Then the bills came.

The patient: Reesha Ahmed, 32, has an Anthem Blue Cross and Blue Shield policy through her employer.

Medical services: An analysis of Pap smear results and several blood tests in tandem with Ahmed's initial prenatal visit, including complete blood count, blood type, and testing for STIs such as hepatitis B, syphilis, and HIV.

Service provider: Ahmed got her tests at Texas Health Mansfield, a tax-exempt hospital jointly operated by Texas Health Resources, a faith-based nonprofit health system, and AdventHealth, another religious nonprofit.

Total bill: The hospital charged $9,520.02 for the blood tests and pathology services. The insurer negotiated that down to $6,700.50 and then paid $4,310.38, leaving Ahmed with a lab bill of $2,390.12.

What gives: Ahmed's situation reveals how hospital-based labs often charge high prices for tests. Even when providers are in network, a patient can be on the hook for thousands of dollars for common blood tests that are far cheaper in other settings. Research shows hospitals typically charge much more than physician's offices or independent commercial labs for the same tests.

The situation was particularly difficult for Ahmed because she had lost the pregnancy.

"To come to terms with it mentally, emotionally, physically — dealing with the ramifications of the miscarriage — and then having to muster up the fighting strength to then start calling your insurance, and the billing department, the provider's office, trying to fight back a bill that you don't feel like you were correctly sent? It's just, it's a lot," she said.

In Texas, the same lab tests were at least six times as expensive in a hospital as in a doctor's office, according to research from the Health Care Cost Institute, a nonprofit that examines health spending.

The markup can be even higher depending on the test. HCCI data, based on 2019 prices, shows the median price for a complete blood count in Texas was $6.34 at an independent lab and $58.22 at a hospital. Texas Health charged Ahmed $206.69 for that test alone.

"It is convenient to get your lab done right in the same building," said Jessica Chang, a senior researcher at HCCI, but "many patients are not thinking about how highly marked up these lab tests are." Chang said she suspects many hospitals tack on their overhead costs when they bill insurance.

Anthem also charged Ahmed for at least four tests that most insurance plans would consider preventive care and therefore covered at no cost to patients under the Affordable Care Act's requirements for covering preventive care, which includes aspects of prenatal care. Her EOBs, or "explanation of benefits" notices, show she paid out-of-pocket for a test identifying her Rh factor — which detects a protein on the surface of red blood cells — as well as for tests for hepatitis B, hepatitis C, and syphilis.

Asked to review Ahmed's tests, Anthem spokesperson Emily Snooks wrote in an email to KFF Health News that the claims "were submitted as diagnostic — not preventive — and were paid according to the benefits in the member's health plan."

There "definitely shouldn't be" out-of-pocket costs for those screenings, said Sabrina Corlette, co-director of Georgetown University's Center on Health Insurance Reforms.

The Centers for Disease Control and Prevention recommends screening pregnant patients for several infectious diseases that pose major risks during pregnancy. Ina Park, a professor of family community medicine at the University of California-San Francisco and an expert on STIs, said the tests Ahmed received didn't raise red flags from a clinical perspective. "It's really more what the actual lab charged based on what the tests actually cost," Park said. "This is a really exorbitant price."

For example, Ahmed paid $71.86 in coinsurance for a hepatitis B test for which the hospital charged $418.55. The hospital charged $295.52 to screen for syphilis; her out-of-pocket cost was $50.74.

"You just wonder, is the insurance company really negotiating with this provider as aggressively as they should to keep the reimbursement to a reasonable amount?" Corlette said.

The resolution: Ahmed refused to pay the bills and Texas Health sent the debt to collections. When she tried to get answers about the costs, she said she was bounced between the doctor's office and the hospital billing department. Ahmed submitted a complaint to the Texas attorney general's office, which passed it to the Texas Health and Human Services Commission. She never heard back.

According to Ahmed, a hospital representative suggested her bloodwork might have been coded incorrectly and agreed the charges "were really unusually high," but she was told there was nothing the hospital could do to change it. The hospital did not comment on the reason behind the high charge. And in a March 7 email, an AdventHealth employee told Ahmed the doctor's office had "no control" over the hospital's billing.

Ahmed filed an appeal with Anthem, but it was denied. The insurance company stated the claims were processed correctly under her benefits, which cover 80% of what the insurer agrees to pay for in-network lab services after she meets her deductible. Ahmed has a $1,400 deductible and a $4,600 out-of-pocket maximum for in-network providers.

"We depend on health care providers to submit accurate billing information regarding what medical care was needed and delivered," Snooks said. Asked about reimbursements to the Texas Health lab, she added, "The claim was reimbursed based on the laboratory's contract with the health plan."

After a KFF Health News reporter contacted Texas Health on Oct. 9, the hospital called Ahmed on Oct. 10 and said it would zero out her bills and remove the charges from collections. Ahmed was relieved, "like a giant burden's just been lifted off my shoulders."

"It's just been fighting this for 10 months now, and it's finally gone," she said.

Texas Health Resources and AdventHealth declined to respond to detailed questions about Ahmed's charges and the tests she was directed to obtain.

"We are sorry Ms. Ahmed did not get clarity on her care with us. Our top priority is to provide our patients with safe, effective and medically appropriate care," Laura Shea, a spokesperson for the hospital, said in an emailed statement.

The takeaway: Ahmed's problem demonstrates the pitfalls of using a hospital lab for routine testing.

For standard bloodwork "it's really hard to argue that there's a quality difference" between independent labs and hospitals that would warrant higher prices, Chang said. That holds true for other services, too, like imaging. "There's nothing special about the machines that hospitals use for a CT or MRI scan. It's the same machine."

Broadly, state and federal lawmakers are paying attention to this issue. Congress is considering legislation that would equalize payments for certain services regardless of whether they are provided in a hospital outpatient department or a doctor's office, although not lab services. Hospitals have tried to fend off such a policy, known as "site-neutral payments."

For example, the Lower Costs, More Transparency Act would require the same prices under Medicare for physician-administered drugs regardless of whether they're given in a doctor's office or an off-campus hospital outpatient department. That bill also would require labs to make public the prices they charge Medicare for tests. Another bill, the Bipartisan Primary Care and Health Workforce Act, would ban hospitals from charging commercial health plans some facility fees — which they use to cover operating or administrative expenses.

According to the National Conference of State Legislatures, Colorado, Connecticut, Ohio, New York, and Texas have limited providers' ability to charge privately insured patients facility fees for certain services. Colorado, Connecticut, Maryland, and New York require health facilities to disclose facility fees to patients before providing care; Florida instituted similar requirements for free-standing emergency departments.

Patients should keep copies of itemized bills and insurance statements. While not the only evidence, those documents can help patients avoid out-of-pocket costs for recommended preventive screenings.

For now, patients can proactively avoid such extreme bills: When your doctor says you need blood tests, ask that the requisition be sent to a commercial lab like Labcorp or Quest Diagnostics that is in your network and have the tests done there. If they can't do it electronically, ask for a paper requisition.

"Don't always just go to the lab that your doctor recommends to you," Corlette said.

KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

Emmarie Huetteman of KFF Health News edited the digital story, and Taunya English of KFF Health News edited the audio story. NPR's Will Stone edited the audio and digital story.