HCA Healthcare has agreed to drop new fees it added for visits to Mission Health's cancer centers, primary care clinics, surgery centers and other specialty clinics and issue refunds to patients who paid them.

The Nashville-based hospital chain made the change in response to an inquiry from North Carolina Attorney General Josh Stein. In a letter to Stein last week, Nashville-based HCA acknowledged that a billing change it implemented across the Mission system on Aug. 1, 2019 created confusion, and agreed to refund affected patients and return to its previous billing method. The letter did not address other concerns Stein had raised.

HCA bought Asheville-based Mission, formerly a not-for-profit system, in February 2019. Before it could close the deal, HCA had to agree to a list of conditions. In a letter in late February, Stein questioned whether HCA was meeting those conditions.

Greg Lowe, president of HCA's North Carolina division, explained in the April 9 letter that Mission had previously billed commercial insurers and Medicare differently for visits to "provider-based departments," which are outpatient clinics that are considered part of a hospital. The change, he wrote, was designed to correct the difference.

More specifically, when billing commercial insurers, Mission had classified visits to its outpatient clinics as freestanding physician offices, meaning there was no hospital facility fee attached. Under the change, which took effect Aug. 1, 2019, more than 20 outpatient clinics became classified as hospital outpatient departments in bills to commercial insurers, meaning the insurers were charged facility fees.

As it turned out, patients became responsible for those fees in the form of copayments or coinsurance. Numerous patients complained about the new facility fees in letters to Stein. They were tacked on to cancer centers, primary care clinics, children's clinics, orthopedics practices, surgery centers and a number of other specialty clinics.

Mission said in a March 18 letter to patients it will refund or write-off the accounts of patients whose out-of-pocket payments changed on Aug. 1, 2019. Specifically, Mission said it won't seek payment for outstanding coinsurance or copayment amounts for patients covered under commercial insurance or Medicare Advantage plans who visits those facilities between Aug. 1, 2019 and March 17. For patients who already paid, Mission said it will issue refunds by May 31.

As for the billing policy, Mission wrote that it has changed its policy so that patients who are seen in provider-based clinics after today "will receive bills similar to the ones they received prior to August 1, 2019."

"We know this has been a frustrating experienced for some of our patients, and we hope these actions help restore your confidence in our medical practices," Mission said in the letter. "We deeply appreciate the opportunity to serve you and this community—and we will do a better job communicating any future changes that impact our patients."

In his letter to Stein, Lowe wrote that the billing change was legal. An HCA representative was not available for comment Tuesday.

Stein originally gave HCA until March 11 to respond to his questions. HCA sent a partial response by that deadline and Stein allowed the company until March 31 to respond to the rest. Now, Stein's office is giving HCA until the end of April to complete its response due to the COVID-19 pandemic, Laura Brewer, a spokeswoman for Stein's office, wrote in an email.

HCA, which has 184 hospitals, posted $51.3 billion in revenue last year, up 10% from $46.7 billion in 2018.