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

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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.


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doctors visit

you are full of it.Most patients do not take advantage of a doctor but the other way around.The md tricked her by asking a question which should have been part of this routine visit. If i go in for a check up and i just want a refill on my rx that takes one minute to write i should not be billed an extra $100 bucks for it just so you can drive a mercedes and live in a 4 bathroom house and send your kids to private school and belong to a country club You dont deserve to be a doctor because you have no compassion for anyone.Go crawl under the rock you came from,doc. By the way i am not a car i am a person. If you want to charge like a machanic why dont you be one?

As someone with a brain

If I went into a doctor's office and asked for an extra hour's worth of medical advice for free, then I'd understand the hesitation. But on the other hand:
My employer asks this of me all the time. Not just my employer. Ask anyone in the military. Ask any scientist. Ask any engineer. Ask any software developer. These people are simply expected to put in more than the 40 hours a week they are paid for. Meeting all your goals? Have some more goals to meet! If you want to keep your job, you'll put in the extra time.

But that aside, the thing that really irks me is the "Price" assigned to the extra medical advice. Maybe some people ask doctors for an extra hour worth of advice, but two out of the last three times I went to a doctor's office, I spoke to the doctor and physician's assistant COMBINED for less than 5 minutes. The third time, I spoke to the doctor for 30 minutes. The bill for each of the three visits? $300. Now for 30 minutes of doctoring, that works out to a modest $600 per hour. Even if the facility charges 200% overhead (which is outrageously high) that's enough for the doc to be earning a cool million per year. But for 5 minutes? Well, that works out to a solid $3600/hour. And I guarantee that doctor isn't pulling in seven figures - so where is that money going?

Now I know that other things go on; there's facilities maintenance, billing specialists, receptionists, and so on. But these don't add up. Other organizations manage the same amount of administrative overhead tasks on much smaller margins.

No one's saying that doctors shouldn't bill for their time. What we're saying is that they aren't billing for their time. The billing is capricious and amoral, and is done in a way to maximize profit within the bounds of an increasingly complicated landscape of healthcare regulation. People shouldn't become doctors for the money (and most I know haven't), just like people don't become scientists for the money, or join the military for the money. But it seems that some people in the healthcare industry can't see that if they aren't being paid enough to own a yacht and a private marina lease, that their services aren't being valued.

And at least my mechanic calls me with a quote for the proposed services first.

I understand what you are

I understand what you are saying but want to share this. I called my doctor and made an appointment for a pap smear and to check my body for any signs of moles etc. that might need to be removed. I go and he performs the pap smear. When I asked about the body scan he stated I needed to tell the desk clerk when I call what I was coming in for. I had done that. So next time I had a visit and requested the visit for several things. Once again I was not given all of the requested checks. So I explained that I had told the clerk when I called. Then he stated we are allowed so much time for each issue. Ok.. then make that clear and post these fees and time as they pertain to these various concerns. No one suggest anyone work for nothing but I fail to believe every issue is a 15 min issue or even a 10 min issue etc. So if there is time remaining that is my time and it should be used for my concerns. And if I explain why I am coming in then enough time should be allowed to handle all of my concerns even if it takes 40 min and you charge not an additional fee but an additional amount. Remember every visit is another co-pay and full charge to the doctor. There has to be a fair medium for all concerned. I do not see this doctor anymore for this reason and another one that I called him on. I respect the medical profession and expect the same. I do not go to the doctor because I want to be there but because I need a service in my best interest. They should be paid fairly but sadly there are many that are using the system in their best interest which is just wrong.

I am also a primary care

I am also a primary care physician, but aware of the delivery of health care issues. I do ask my patients about whether they are insured and what they are covered for. If you are coming for an urgent care visit and being billed for what you are asking to be seen for then its a patient's responsibility to make sure that is covered for them. If you are coming for your well-care of preventative health visit in which the physician is already being covered for what should be a full exam then what a physician finds being negative or positive should not then be separately billed. The visit was for a physical, the pt was covered for a physical and the physician reimbursed for a physical. If f/u is needed for a finding then separate reimbursement comes for that f/u visit.

Yeah, right. You're going on

Yeah, right. You're going on about things that aren't even what the original poster is talking about.

This is the problem I see. What about when I go to see a doctor and pay for his time. I say my office visit should be at least 15 minutes. I should be able to discuss whatever I want during that time period without being charged extra. But alot of times the office visit is just 5 minutes. So, should the doctor then charge for a full office visit when he decides to run out of the room after just 5 minutes?

I've had some doctor visits that last less than 5 minutes. I don't see why that should then be hundreds of dollars.

That sounds like a great business model though. Cram in so many patients so you only have minutes per office visit. So, you're making thousands and thousands an hour. Then charge extra if the patient asks a question that extends the office visit to a minute or so longer.

I think the problem is doctors bill things to insurance companies. So, they can bill whatever they want as the customer just pays their usual copay. So, there is alot of padding and overcharges in billing as it just goes straight to the insurance company.

That doesn't generally happen when say you have a car fixed by a mechanic. As they have to tell you up front what they are doing and how much it will be.

In contrast, you can be in a doctors office. Say "hi" to the doctor. Then get a bill in the mail for an office visit of telling the doctor "hi". Obviously I'm joking on that last one.

As a primary care doctor I

Are you full of excrement? I asked questions during my physical and got swiped with an additional visit. My total time in the office, <15 min. If you asked for an oil change and someone changed your brakes without calling and telling you the price to do so AND you accepted it, you're an idiot! You would have the option to tow it somewhere else at an overall cheaper price.

You have a written contract with your employees to pay them an hourly rate (none of the documents I read in my agreement with my doctor noted any BS about answering a question during a physical would cost any extra - nor does it have an hourly charge). So if I have two problems, say an earache and a rash, I will get charged for two visits? EFF YOU

The doctor asked me if I had any additional questions with no indication of additional cost, so I asked. If I were to ask if it will cost me extra, do I then get charged for asking a third question. You are full of S$#T! I now have to ask prior to any question if there is an additional charge for my question. Grow some balls and tell your clients before you screw them you cowardly P.O.S. Rot in hell you crook.

doctors visit

Like your response.Couldnt have said it better myself.

It was not a by the way

It was not a by the way question, the doctor asked if there was anything else she wanted to discuss. This was a physical where you talk about any problems you may have.
You completely missed the point!

If I could find a competent

If I could find a competent doctor that also has a healthy dose of compassion, I'd sell my soul to keep him/her happy.
I can't find a combination, and I've had many issues with my spine for many years.
If they are reasonably competent, they are so arrogant that it doesn't matter what you say to them. They will never see you as a human being, only an account # that pays or does not. Most of the time they won't even review a file before handing down sentencing...
If they have any compassion at all, never mind, I can't remember any...
Just self styled gods that pass judgement, either with an adequate file review before said judgement, or not.
Stealing your livlihood? You guys are robbing us blind, and more often than not, not even bothering to show us the respect you would for your dog while you're at it.
Why don't you quit complaining??? You obviously hate people by the way you talk. You'll know you've got us over a barrell, so you basically get away with sub-standard care at bankster prices.
The vast majority of doctors belong in jail, right along with the banksters, and politicians, but you'll should face harsher recriminations because you're playing with peoples' health...
Get a job working with machines. You obviously don't have the compassion, or intelligence to work with people, and I wouldn't trust you with an earthworm.
The worst part??? You're probably my doctor!!! You're at least a clone!!!

To the primary care doctor's comments

This "doctor" is the perfect example of why healthcare is basically untouchable my a lot of people.
You are comparing a mechanic fixing my breaks because I casually asked him to check them with you charging for answering a patient's question with" I don't see nothing in your throat" ? Are you serious?
First of all, if I asked a mechanic to check my brakes, that is exactly what I expect him to do! I did not say Fix my brakes! I only asked him to check them!
Most mechanics do not even charge for checking the brakes since it is such an easy task and only requires a visual inspection. They do that because they are checking to see if they can get more business by finding bad brakes and then asking if they can go ahead and fix them.

You F*&%ing "doctors" don't ask patients if they want to get billed for every word that comes out of your mind. You just charge it because you think you are entitled.
That is wrong! Even if you charged extra for takin 2 minutes to look in someone's throat including asking them if there was something else, how can you justify the 100 dollars? People pay for a service not for your medical school. You are not God and in fact you're just another schmuck eager to fill up his bank account.
The fact is that you are out of control ( all of you docs) You should be required by law to justify your billing statements. Some of you asses don't even bother to explain. You just simply send a generic looking bill requesting payment for a total amount. I'm supposed to call and ask what i'm being charged for.
Thereis no accountability and no repercussion. Thats why we are where we are.
I find obscene for family doctors who are just a bunch of pill salesman to charge 100$ for 10 seconds worth of looking in somone's throat.