JOHN YANG: The next time you go to the doctor's office, you may not know whether or not they're affiliated with a hospital system.

If they are, your bill for a routine visit may include some surprising extra charges fees that go to the hospital even if you never stepped a foot inside it.

Special correspondent Megan Thompson has our report.

MEGAN THOMPSON (voice-over): In 2016, Jess Ayers and her family moved from New Jersey back to her home state of Minnesota.

Ayres set about making appointments with new doctors for her three children, especially her daughter, who needed regular eye exams.

JESS AYERS: She was diagnosed with strabismus, which is essentially a lazy eye.

MEGAN THOMPSON (voice-over): So they took her to an ophthalmology practice at this clinic in Minneapolis that had been recommended by their old doctor in New Jersey.

After the checkup, Ayres was surprised to receive two bills, one for the physician's fee and one for hospital charges totaling $176 AERs.

JESS AYERS: It was very puzzling and frustrating.

MEGAN THOMPSON: Had you gone to a hospital?

JESS AYERS: No, we had not gone to a hospital.

Right.

This was a doctor's office.

MEGA THOMPSON (voice-over): Ayres discovered the doctor's office was part of a hospital system called M Health Fairview, one of the largest health systems in the state.

So Ayres, who works in healthcare communications, had to pay something called a facility fee.

JESS AYERS: I was dumbfounded because I'd never heard of it, and having worked in health care for a long time, I was taken aback.

MEGAN THOMPSON (voice-over): She's not alone, says Christine Monahan, an expert on facility fees at Georgetown University's center on Health Insurance Reforms.

CHRISTINE MONAHAN, Georgetown University: Facility fees are particularly pernicious because there are these high, often surprising bills that are not really adequately covered by our insurance.

MEGAN THOMPSON (voice-over): Monahan says hospitals have traditionally charged facility fees to help cover their overhead costs.

But more and more they're charging the fees for routine outpatient care.

CHRISTINE MONAHAN: Two things are at play.

One is that hospitals are increasingly acquiring physician practices.

More and more places you go to will be affiliated with the hospital.

MEGAN THOMPSON (voice-over): In fact, between 2012 and 2024, the percentage of doctors employed by hospitals or health systems more than doubled to 55 percent, which helps explain why it seems more Americans are being charged.

CHRISTINE MONAHAN: But we're also seeing them more.

Consumers are feeling them more because we're seeing deductibles increase in our insurance coverage.

And so more and more you might be directly responsible.

MEGAN THOMPSON (voice-over): Nationwide, insurance deductibles have increased by nearly 50 percent in the last decade.

Jess Ayers current insurance plan has a high deductible of $10,000 for her family of five.

JESS AYERS: You know, there's a lot of those types of bills.

They come in every which way and it's a little bit like death by a thousand.

Paper cuts.

MEGAN THOMPSON (voice-over): Kaitlin Johnson of Minneapolis says she was prepared for a facility fee when she took her eight-year-old daughter for a panel of 40 allergy tests last summer at this M Health Fairview clinic.

But she was not prepared for how much the actual tests would cost.

KAITLIN JOHNSON: The total they charged to insurance was $24,400.

MEGAN THOMPSON: $24,000.

KAITLIN JOHNSON: Yes.

MEGAN THOMPSON (voice-over): Insurance paid almost $19,000, and Johnson was left to pay more than 5,400.

MEGAN THOMPSON: I mean, what went through your head when you saw that bill?

KAITLIN JOHNSON: Shocked and really confused because, you know, part of me felt like, how did I not know that this was such an expensive test?

MEGAN THOMPSON (voice-over): It turns out it's actually not.

KAITLIN JOHNSON: I'm just calling to see if I can get some pricing information.

MEGAN THOMPSON: Johnson called around to allergy clinics not affiliated with hospitals and asked about a panel of tests similar to what her daughter had.

WOMAN: Testing typically runs about $1,827.

WOMAN: Could run anywhere from 800 to 1.800.

MEGAN THOMPSON (voice-over): And that's the price before insurance kicks in.

Johnson thought her clinic had made a mistake, but they assured her they had not.

Saying there is a big difference between hospital pricing and freestanding clinic pricing.

So now she's fighting the bill.

KAITLIN JOHNSON: This test was outrageously expensive and seemed extremely out of line.

MEGAN THOMPSON: High prices, Christine Monahan says, are another consequence of hospitals consolidating and buying up independent practices.

The larger they are, the more negotiating power they have with insurance companies.

CHRISTINE MONAHAN: The greater the market power that a hospital has, the higher prices they charge for their services.

MEGAN THOMPSON (voice-over): High procedure prices and facility fees are helping drive up the cost of hospital care, which has been growing about twice as fast as inflation and outpacing physician services and prescription drugs.

What do they pay for?

MEGAN THOMPSON (voice-over): To understand what's behind the surging prices, we spoke to Molly Smith of the American Hospital Association.

MOLLY SMITH, American Hospital Association: First and foremost, there is no place in the healthcare system like a hospital.

We uniquely provide the highest level of care.

MEGAN THOMPSON (voice-over): Smith says operating hospitals is expensive with their round the clock emergency departments, top of the line medical equipment and highly trained specialists.

MEGAN THOMPSON: A patient walks into a doctor's office for routine care and they're not using any of those hospital resources.

So you can kind of understand why they would say, why am I paying for them?

I'm not getting anything.

MOLLY SMITH: But I do think everyone needs to understand what it takes for hospitals and health systems to maintain access to care in their communities 24 hours a day.

When you need your emergency department in the middle of the night, you need it to be open and available.

MEGAN THOMPSON (voice-over): Smith says inflation has made it all the more expensive, and hospitals are not being reimbursed enough by insurers to cover all the costs.

MOLLY SMITH: Insurers payers are squeezing providers to the point where they are no longer financially stable.

For every dollar that a hospital spends on staff on medical supplies, Medicare only reimburses them $0.82.

They have to make up that other $0.18 somewhere else.

MEGAN THOMPSON (voice-over): But state legislatures are increasingly cracking down, saying that gap shouldn't be made up by raising costs for routine care.

CHRISTINE MONAHAN: We've seen 20 states nationwide take some type of action to regulate facility fee billing.

MEGAN THOMPSON: And when it comes to reining in prices for procedures, a bill proposed in New York state would be the first to cap prices at hospital outpatient clinics for people with commercial insurance, people like Kaitlin Johnson with her daughter's $24,000 allergy test.

In a statement to PBS News Weekend, M Health Fairview said, we understand that health care billing can be complex, and we recognize that the cost of care a significant concern for many individuals and families.

After eight months of Johnson fighting her bill and after inquiries from PBS News Weekend, M Health Fairview finally agreed to waive her balance.

They also told her they've decided to reduce their price for allergy tests by more than 80 percent.

As for Jess Ayers, she found she could avoid the facility fee by driving her daughter to a different clinic 40 minutes away in a far off suburb.

Even though it's the same doctors and health system.

JESS AYERS: You almost like had to shake your head and be like, what?

MEGAN THOMPSON (voice-over): Luckily, Ayers could afford to pay her bill, but she still worries about those who are less well-off and about people like her parents who live in rural northern Minnesota, a two hour drive from their doctors.

JESS AYERS: And there's a lot of country out there and there are a lot of people who are further from care.

And if they only have a choice to go to a facility that does charge a hospital fee, what then?

How is that fair?

MEGAN THOMPSON (voice-over): For PBS News Weekend, I'm Megan Thompson in Edina, Minnesota.