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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primary care doctors comments

Require a law to justify their billing? Your kidding,right? The rich make laws for the rich not people like us.Wealthy congressmen wealthy doctors. Need i say more?

I don't speak to represent

I don't speak to represent all doctors. These are my own thoughts.
The poster should do some homework before posting.
Doctor can't charge what we want. Unlike most any other business (this is a business-not a charity) our rates are dictated by insurance companies and the government. Yes rates are based on what medicare (a government program) is willing to pay. There are some services we provide (because it is the right thing to do) that we lose money on. How many businesses do that?

We have to justify every billing we do-every one for every doctor. They are audited regularly to make sure what is done is justified.

As the cost of doing business goes up (pay raises for employess, cost of paper, cost of computers, repairs, malpractice) the charges remain flat or in the case of Medicare potentially go down (20% cuts threatened every year.)

The mechanic analogy is valid. If he didn't stand to earn your business and sell you brakes and charge you labor at whatever he wises to set that rate at he would not look at your brakes. He is not in this for charity either.

How many of you go into your employer and give your time for free. "The economy is bad so why don't you just not pay me for a few hours this week." You don't do this because you consider your time/energy worth something. My time is worth something to me.

Malpractice cost are a problem because when some patients don't get what they want or things don't end like a disney movie ending they are calling a lawyer.
Fine you want it that way, somehow that insurance has to be paid.

Good look finding Dr McDreamy-Schweitzer-Doolittle or whatever you want.

There in lies the problem.

There in lies the problem. Doctors will use different codes to charge whatever they want. I went to the emergency room because I hurt my finger. The doctor that saw me was in the room for less than 2 minutes, and they billed $1605.00. Are you F*%#ing kidding me ??? I thought it was a mistake. When I called the insurance company, they said it was perfectly legal for them to classify it as a surgery. WHAT??? What planet am I on? Unbelievable. This is exactly why we are in the mess we are in. Anytime there is an opportunity to take advantage of the system, only a few can walk away honestly. The system needs to be changed.


My uncle was a doctor. He never charged people who didnt have the money. Instead, he bartered. Maybe if the patient was a carpenter, they would help my uncle fix up his house. If they were a mechanic, they'd fix his car, a baker, give him some bread.
sure doctors offices arent charities but you guys are insane with your prices. 5 minutes for 500$????

With all due respect...

Please recall that the doctor contacted ME and told me to come in for the exam. I did not seek her services. During the exam, she also asked ME if there was anything else I wanted to talk about. Unprompted, I would have ended the exam prior to that question, and I was certainly ready to get out of there. I had to think to come up with anything else to talk about. I think she was fishing for extra charges.

And yes, this wasn't the only time something went awry. Several years prior to this incident she had gravely misdiagnosed a red, painful wrist as an antibiotic-resistant bacterial infection. She told me I had to go to the hospital immediately upon leaving her office, check in and get an IV put in. She literally told me I had a 50% chance of dying if I did not follow her orders immediately -- pretty alarmist conclusion. I sought a second opinion, which revealed I had a condition that was inexpensively healed with a splint and some anti-inflammatory medication. She never apologized for her gross error. Another time, she diagnosed me with a cellular irregularity. She referred me to a specialist who told me I was completely normal and suggested that my doctor had accidentally switched my slides. I relayed the specialist's comment to my primary doctor. Apparently she didn't like hearing it, and I got the brunt of her anger over it. So there was more to the story, but it only reinforces that she is a poor doctor who is essentially an alarmist, that she is likely an egotist always believes she is right and who opportunistically fishes for extra charges.

Anne Landman

Continuing the Mechanic Analogy...

My mechanic calls me and suggests that it is time for an oil change or a tune-up (I do these myself, by the way, and have never had him do them), my dentist calls to tell me it is time for a cleaning and check-up too. Sure she was trying to get business, that is her livelihood. I know nothing about the quality of your physician, and I cannot defend what you say were misdiagnoses, but if you thought she was so bad, why did you keep going back?? Sometimes patients don't remember things very clearly, though. Just yesterday I saw a patient that complained that I had referred her to a specialist in blood disorders and insists I told her she had leukemia, which she did not have. That is, of course, preposterous because there is no way on the limited data I get as a Primary Care that I could have given her that diagnosis. I also distinctly remember the conversation in which I suggested the consult. She wanted to know why I wanted to refer her there. I replied that the most concerning thing that she could have was leukemia, but it could be normal for her, and it needs to be checked out further. (I would never tell someone they have leukemia, I'm not a Hematologist or Oncologist) The more you describe this situation, the more it sounds like your view is rather self-serving and narrow-minded.

Health Care Cost & Doctors

Anne, This is an excellent post. I like doctors to, after all they help us stay healthy. However doctors should not be able to charge whatever they want. Many people assume it's all the insurance companies fault. But is it fair for one doctor to charge $100 for a general exam, and another doctor in the same city to charge $300 for the exact same service? That is why most insurance companies research the average fee charge in an area for that service and may only pay for the average fee charged. Doctors could charge a lot less and still make plenty of money. If government regulated what doctors can charge it would cut cost for insurance companies, and employers and the savings would be past on to the consumer. I wish people would spread the awareness. I am not out to defend insurance companies. However consumers need to know the truth. The health care crisis in America is not all the insurance companies fault.

You really don't know what you are talking about

And repeating the things you are saying clouds the picture of health care costs. Doctors cannot charge anything they want. The doctor who charges $100 gets paid exactly the same as the doctor who charges $300 for the same service because insurance companies set the amount the physician gets paid, not the rate the physician charges. You said, "...most insurance companies research the average fee charge[sic] in an area for that service and may only pay for the average fee charged..." You are partially right - ALL insurance companies know EXACTLY what the other physicians in the area get paid because they determine what they get paid! And, it is ALWAYS regulated by the prices that the government sets, because all contracts are based on Medicare reimbursement. I now have a solo practice, but I was employed by a large group before. The CEO who only had an MBA made 3 times what the doctors made. The CEO of the hospital where I see my patients makes 10 times what I make, and he only has an MBA. If I didn't like practicing medicine and taking care of my patients, I would go back to school and make a LOT more money!

Who can afford to see a doctor, anyway?

Our insurance allows one visit per year with a $20 co-pay. If the visit is coded with a medical diagnosis instead of as a routine checkup, our insurance won't cover it.

Our long time physician recently hired a new insurance clerk and she refuses to code with anything other than a medical diagnosis. To make things worse, the office has recently changed policies requiring payment up front for the office visit ($150) instead of just the co-pay and waiting for the claim to clear to pay any balance.

My new American healthcare plan is to stop taking the medication I have been prescribed and wait until something happens that requires emergency care (no, not using the ER as a physician's office...something truly dire). Our insurance will cover that, less a $50 deductible. We simply cannot afford "routine care" any more.

acne "surgery"

I went to my dermatologist in nyc for adult acne - this was a follow up visit to get new prescriptions. The doctor wrote me 2 Rx and scraped some blackheads from my nose with a tool you can buy at the drug store. The office billed my insurance $400 for the visit and $600 for acne surgery. I paid a $50 co-pay, and the insurance company applied the bill against my deductible, after adjusting the charges signifcantly lower with the explanation "discount". Bottom line, I received a bill for an additonal $84. I refuse to pay an additional amount on the principle that no surgery was performed. I was not told that scraping my nose would cost me more than the co-pay for an office visit - I wasn't even asked if I wanted the service, he just did it! I called the office and explained I thought the additional charge was unwarranted, and the billing clerk told me "we bill anything acne related as surgery.." So why not bill $10,000 for dermabrasion if you're looking to milk your patients/insurance companies? I'm going to call back or send a polite letter saying I disagree with the charge and believe my standard co-pay is reasonable for the services perfomed.
What do you think? Will they send my bill to collection for the $84 balance?