This Is Going to Hurt: What Your Doctor Doesn't Say Can Cost You

Share/Save Share this

examination day surpriseInsurance companies are hot targets right now in the debate over skyrocketing medical costs and health care reform. But there is another, little-noticed factor could also be sucking untold health care dollars out of our pockets, and it's one we seem loathe to address: the part that doctors themselves have in quietly pushing up the costs of our medical care. This is an area that is begging for closer scrutiny, and in which patients need more help.

An Examination Day Surprise

My interest in this topic was piqued recently by a personal experience that brought home the problem of runaway medical costs in a rather shocking way.

In August my doctor sent me a letter telling me it was time to come in for a physical exam. My last physical was years ago, so it seemed like a reasonable request. I made an appointment and went in for a check up.

Throughout the exam, the doctor peppered me with the usual questions: how have you been feeling? How have you been sleeping? Have you had any problems with this-or-that? As she wrapped up the exam, she asked if there was anything else I wanted to talk about. After thinking for a second, I mentioned a lump I'd been feeling in my throat with the onset of fall allergies. She took a quick look in my throat, dismissed the problem, said nothing could be done and concluded the exam.

A week and a half later, I got the doctor's bill. It listed a charge of $180 for the physical, but it also had another charge I didn't recognize: "EP Visit Low Additional -- $100." Puzzled, and pinching pennies due to my economic situation, I called the doctor's office to ask what the extra $100 charge was for. Her assistant told me it was for that moment in the exam when the doctor asked, "Is there was anything else you want to talk about?" and I had brought up the lump in my throat. The extra minute the doctor took to dismiss the problem resulted in an extra $100 charge, the same amount she charges for a completely separate, one-issue visit.

I was floored. "One-hundred dollars? For that?" I said. "I thought that question was part of the physical exam! It took the doctor less than 60 seconds to tell me she couldn't see anything and couldn't do anything about it," I said. The assistant told me the $100 charge wasn't just to look in my throat -- that it paid for the cost of the doctor's attending medical school, which enabled her to look in my throat and tell me she didn't see anything. I told her that the way this charge was leveled felt like a trick, since the question -- "Is there was anything else you want to talk about?" -- was asked as though it was a regular part of the physical exam. No one warned me that if I answered this question with anything other than a "No," it would lead to such a hefty extra charge. How was I to differentiate this question from all the others the doctor asked during the exam?

The assistant declined to offer any further explanation. She didn't propose discussing it with the doctor, asking the doctor for an adjustment, or any other potentially mitigating measures. The call ended in a stalemate.

Two days later I received a certified letter from my doctor, dumping me as her patient.

What's a Patient to Do?

Well, okay, I guess I made it pretty clear -- after essentially accusing my doctor of tricking me -- that I no longer trusted her. And it was probably a reasonable assessment on her part that she could no longer treat someone who had lost trust in her. She might have made some effort to win back my trust, but apparently she concluded it wasn't worth it.

On an emotional level, I felt exploited. My doctor, whom I had long trusted, had just treated me like an ATM. That hurt more than any shot, but it also got me thinking about the larger meaning this incident may have in the spiraling cost of health care.

The more I looked into this event, the more it looks like the perfect way that doctors can, and apparently do, pad their outpatient medical bills without repercussions.

The "Golden Question": Business as Usual or Medical Billing Fraud?

Dropping this "golden question" on an unsuspecting patient near the end of a routine physical exam, and taking advantage of even the most minimal response to add a whopping extra charge to the bill, appears to be a near-perfect way doctors can safely increase their billings. Consider this: there are only two people in the room when it happens, making it a he-said, she-said situation that renders any accusations hard to prove. What's more, insurance companies have to take a doctor's word for what happens in an examining room; if a doctor charges a fee for doing something in there, insurance companies cannot question it. They have to pay. Insurance companies depend on policyholders to contest any inappropriate extra charges, but how many patients have the chutzpah to risk offending their doctors by questioning a charge? And if a patient does summon the courage to dispute a charge, it's the doctor's opinion against the patient's about what level of value was delivered at that moment in the exam. Whose opinion would hold more weight in that dispute? The unknowing patient, or an all-knowing doctor? And after reading about how my doctor dumped me like a hot potato after challenging a suspicious charge, who in their right mind would do it?

A patient in this situation is both vulnerable to extra charges and at an extreme disadvantage to challenge them, with notoriously little recourse. This makes the "golden question" billing strategy close to a perfect way for doctors to bilk patients and insurance companies out of millions.

We have no way to know how pervasive this practice might be, or what it could be costing.

What's the Answer?

Is there a plausible solution to this situation? Should doctors be required to post a listing of their fees for all services in full view of patients? Warn patients before they ask questions that might result in extra charges? Should the savvy patient, sitting half naked in a hospital gown, stop the doctor after each question and ask how it should be answered to determine whether an extra charge will be incurred?

These ideas are clearly ludicrous, but it is also ludicrous that patients be put in such a one-down position. My doctor responded to my challenge of a questionable charge by demonstrating to me -- rather heavy-handedly -- that she was in control, not me, and that I would be punished for questioning her.

Buyer Beware. Yes, Even With Doctors

I like doctors. I really do, and I really want to trust them. After all, I grew up watching shows like Marcus Welby, M.D. and Medical Center, and even my own mother is a doctor, and so is my brother. That my long-time physician -- whom I wanted to believe had my best interests at heart -- would rip me off by padding my bill is onerous, and disappointing in the extreme. The speed with which she dumped me after I questioned the charge did everything to raise my suspicion about the situation.

This is but one more on-the-ground experience that points out the wrongness of delivering health care as for-profit business model. The current, for-profit system fosters adversity between patients and doctors. It discourages patients from disclosing conditions that might be costly to address, and that could become even more costly later, and, frankly, it is a system that makes engaging in fraud more attractive to doctors.

As long as our current health care system operates by selling services to consumers the same way as an auto repair garage, a plumber or a building contractor, consumers have every right to question charges on their bill without being intimidated or subjected to punishment.

To truly function in the best interests of doctors and patients alike, the American health care system needs to be reshaped to put doctors' focus on health, not money.

We have a "golden" opportunity to change it now. Let's hope it happens.


Comment viewing options

Select your preferred way to display the comments and click "Save settings" to activate your changes.

Right way

I had read and I got some experience from that.

non-insured visit cost

Yes, there needs to be a "real" regulation on what doctors charge for an office visit and the time allowed for that visit specific to the visit. There was a time that seeing a doctor did not result in just a specific issue but the doctor would entertain a question that might arise during the visit regarding another concern. And at one time you were seen for several things at the same time. Now they want you to schedule for every single thing separately. And if you are uninsured the doctors are charging huge amounts for a visit. How does $300.00 sound for a single office visit. Plus they are requesting cash. Does that lead one to believe they are hiding income? It is out of control. They have put themselves in financial ruin buying large facilities while the public can not afford insurance or visits and have decided food and shelter is more important than seeing a doctor or taking meds. Meds are also out of control. The pharmacies are loaded with scripts. No doubt the doctors get a kickback form prescriptions which should be illegal plain and simple. It is a conflict of interest without a doubt. The doctors are just waiting for the babyboomers to roll in to line their pockets across the next 15-20 years. Is anyone paying attention to this issue. Sad state of affairs for sure.

A failed system

I can only guess why things went as they did in this patient's encounter. A number of motivations come to mind which are too numerous to describe here. She points out, however something I have noted which is that some of my colleagues have become experts at gaming a system that rewards for doing more. One sign of a person's shift from compassionate care is a doc's shift in everyday conversation from care issues to material things or money-making schemes.
A system that rewards one for the skill in handling cases, outcomes, interpersonal skills and all the things desired in a "good doctor" would be ideal but hard to develop. Attempts are being made to incorporate this but with little data to support the metrics so it is a little scary for the average doc who just wants to give good care. Best, I think, would be to support and incorporate the best models out there, such as at the Cleveland Clinic where doctors are salaried and not paid by production and number of procedures.
I am in emergency doctor. I don't do "wallet biopsies" and can't (and don't want to) choose my patients. I like that but is is not for everyone. Most emergency docs burn out and retire or move to something else by my age. My heart goes out for patients with limited means and I will game the system to save them a few bucks. Universal healthcare would solve that problem. Obamacare is only a start. It has deep flaws and will get bad publicity but keep aware of developments and lobby your representatives to improve it. Be aware that corporate interests are always trying to improve their bottom lines so look at where their lobbying money goes and press for alternatives. It's tiring but eternal vigilance is more important now than ever.

Same experience

I just had the same thing happen to me. As appalling as i think this practice of charging extra is, at least people should be made aware that they might be charged extra beforehand. As a matter of fact, I think a complete listing of all charges that may be incurred at the office should be available in a stack in the lobby for full disclosure and under what conditions more charges might be added. I also think, to the doctor who posted,... if you are not willing to hear some griping and complaining from patients at a physical exam, then I believe you are in the wrong line of business.

Doctors didn't choose this way

As a Primary Care doctor, I did not choose the way things are billed. This is the system I inherited when I became a doctor, and it was set by politicians and bureaucrats, not doctors. Do we have to bill this way? Sure, it is the way we get paid for our job. I hate it. And, by the way, many other doctors (most, I think) do too. The system is supposed to be designed (again, not by doctors) to reimburse physicians more money for more work done, but some patients demand more time for a physical than others, and the reimbursement is the same. The rules say (rules, once again not designed by the physician, and that this physician was following) that if there is an acute complaint in addition to a well patient visit, as there was in this case, that the physician should submit an additional charge. Perhaps physicians should get reimbursed a set dollar amount for each problem addressed, and get paid according to a set amount based on how much is determined he should make for addressing that problem, the same way a mechanic gets reimbursed so much for a tune-up, so much for an oil change, so much for changing the alternator, etc., and gets paid for each job he does. That way, if a patient comes in for high blood pressure, kidney disease, cholesterol issues, and diabetes, the physician would get paid a separate fee for addressing each of these. That would certainly have satisfied this patient since they would have known that if they gave the extra complaint to the doctor that it would include an extra charge. Many Primary Care Physicians are going to the Concierge Medicine model, where patients pay a fee (usually $1500 per year) to be a patient of the physician, then they get a certain amount of time with the physician as dictated by his policies.

Right ON!

Very well written. I totally agree and had a similar experience.

no profession is fool-proof

There are good and bad providers in any career field; however, when playing with your health, it is vital that you find someone honest and caring. Holistic treatment takes everything into account. Remember - due diligence.
Tampa chiropractor
Tampa backpain

Very interesting story Anne.

Very interesting story Anne. Just had this happen to us. However, they waited 6 1/2 months to bill us for the extra office visit. Our son went to the Doctor in December for a physical. My husband had just been laid off and we all wanted to get into see the Doctor before our insurance ran out. Just like you, he asked our son if there was anything else that was bothering him. Our son said yes, his knee, it had been. He gave him a brace and sent him on his way. He never wore the brace. I guess my son was trying to think hard about what else. When we received the first bill it actually had been through our insurance and none of it had been paid, the visit or the brace. So my husband unwittingly called the billing department and told them it had been a physical. Now we are being charged for another office visit over 6 months later.

I also find the doctors justification a little interesting. He feels totally justified, scary huh! He doesn't even see why that would be a problem for most hard working fair minded people. You can get so far out of touch with whats right and wrong that you can't even think logically anymore.

My husband found himself eating lunch right after I talked to him after talking to the billing department with an old friend who happens to be a cardiologist. He related my story, he said that he said that at conferences, where Doctors go to learn more about medicine they are also taught how to garner more income through billing and how it's related to insurance. He felt the whole practice was unfair, there are good Doctors out there. But there are also a slew of Doctors who are being feed a bunch of making money hype and if you're in it for that reason I can see how they all get twisted up in there heads in believing it's fair and reasonable. We just all know it's not And if he just recognized that it's just not about making a living, I'm all for that!, it's really more about a standard of living. We're not blind---goof ball!

Doctors are poor businessmen

The most likely thing to get messed up by a doctor is your bill. We are not trained in most cases to run a business, but of course, we do after we leave school. I took additional business courses in medical school, so I know my practice well, and monitor that aspect closely. However, most doctors have no idea what the bill is for the services they render. That is usually handled by other people.

As a primary care doctor I

As a primary care doctor I sympathize. The response from the doc was heavy handed but appropiate. Day in, day out I have patients that mention the dreaded "By the way" as we are concluding our visit. Or the similar "While I am here..." "My wife says I have to mention...." at the end of the visit. Many of these are addressed in a professional manner but some...!

Imagine going to your mechanic for an oil change (routine maintainence) and while the car is on the lift say hey while your in there check the brakes -They make a horrible sound (problem based symptom).
Ethically you don't want anyone to get hurt so you do the service and CHARGE for it. You don't give it away. I'm always pissed at the labor change for the mechanic, washer repair man (Really 60 min minimum for service call) but I accept that I am not trained to do these things or do them right.
As a physician my skill is my ability to sort out illness/disease and treat as needed or possible. If you ask me at a cookout to look at something or about your particular case then you are stealing my livelihood. Kind of.

FYI- My guess is that the writer was not discharged for this one occurance. Many of my pain in the ass patients are tolerated for years before a straw breaks the camel's back. You just iced the cake that day.

I will try this new concept on my employees first. "SInce you are already here I am going to have you work an extra hour and I don't want to pay you any extra for it." "It would be unethical for you to leave and deny care to my patients."
I will also ask my dentist while he is pulling my tooth that he go ahead and pull the other one for the same charge and that then point out to him it is is unethical to charge me more for doing so.
In fairness I will put a fresh fish market white board out front to advertise my daily rates. Sore throat $40, Physical exam $80, Fibromyalgia $750. Listening to all your whining about health care costs, drug cost, gas prices-still seeing you (beyond your scheduled time)-foregoing a paycheck when my office can't meet payroll---Priceless. No really, no price-It was probably given to you by me for free.