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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The key to this is taking the profit motive out of health care.

I believe that the best way to address problems regarding the cost of health care is to make medical care less about rendering quantity of procedures & drugs and more about improving the health of the patients. If the focus of pricing becomes based on results rather than processing, then we would all be subjected to less processing and better results. More results are not needed. What's needed are better results, better efficacy. Also, the status of contract law needs to be changed from allowing for dismissing or signing away of a person's rights to a recognition that rights are stated, in the founding documents of this country (the United States of America), as being inalienable. Statements in founding documents of a nation should be regarded as binding, especially if those documents are generally used to promote that nation as an exemplar for all regarding systems of government.

warning of extra charge-with a twist

Ironically, it is comforting to learn that we are not alone in being charged extra for an annual physical.
I scheduled a physical last month, and, within a few days of making the appointment, I received a packet from the doctor's office. In this packet was a letter informing me that the insurance company is the bad guy, and the doctor's office is the good guy. It said that the insurer wants the doctor to do only a wellness visit on one day, and address any chronic or acute medical issues at another visit, another day. The doctor's office says that isn't good medical care, and they don't think it's very logical or convenient for the patient. Their position is that an "annual health review" should address all three issues-preventive, chronic, and acute (if appropriate for the patient)- at one visit. Sounds good, right?
Wrong. They go on to say that they bill for their services according to nationally recognized standards; that for patients with chronic or accute medical issues at the time of their annual review, two services may be billed: a preventative medicine service, and an office visit.
I called and cancelled my appointment for a physical.
My husband and I go to different doctors, but both practices are part of the same large medical chain in our area, Eagle Physicians. When we finally received the statement for my husband's physical two months ago, sure enough, there was an extra charge of $94 for an office visit. He doesn't remember getting a warning letter, but he is going to call and ask what exactly triggered the extra charge.
This practice is so subjective! At what point does the doctor think to themselves, "If I answer this patient's question, I can charge them for another office visit"??? My sister and my friend go to doctors who still do it the right way - anything that is going on with you at the time of your physical gets addressed, for one charge. Period. I'm now looking for a new doctor.
I would just like to know how widespread is knowledge of this deceptive and unfair practice?

extra charges

Nationally recognized standard? Yes ,made up by of DOCTORS of course,not the government.The government only gets involved with charges when it is medicare or medicaid. and insurance companies negotiate prices. They do not tell you how many office visits to charge for.All you cronies get together and decide to screw patients by charging them two copays for two visits. So do not shift the blame on someone else.You can blame the CEO s and yes I do believe that was the start of medical care rising but since so many of you are validating billing for two visits your as guilty and crooked as they are. You should be ashamed of yourselves. You are suppose to heal not hurt people by padding your bills.People are sick when they come to you and when they get your dramatically inflated bills they sure dont feel any better. You give me pills for high blood pressure and then you make it go higher with your bill.When I am in your office I would like to be able to trust you not have to concern myself with being billed ala cart. What ever happened to do no harm? Shame on you all.

This is not deceptive...unfair??

I addressed this in an earlier comment, but I want to reiterate, doctors did not choose or design this system, and we don't like it. The government designed this system, and the insurance companies followed it. To answer your question, if you go to your doctor for a physical, that means they are looking for nothing to be wrong with you. If you complain about ANYTHING, that is called an ACUTE COMPLAINT, and gets an extra charge. The idea (set up by the government) is that if you had something wrong (i.e. the acute complaint), you should have seen your doctor about it before your physical exam, not to wait until you have a physical. And yes, the Medicare system, and most insurance companies have followed, want you to go for a physical when you have nothing to complain about just to get screenings, and do not want you to wait until you go to the doctor for a physical exam to address a problem. Often they will not pay for something extra at the physical exam and want you to be scheduled for a different time. I will address small concerns (as in this article) without putting in a charge for it, but if there is a major new complaint, I reschedule the physical exam and address the acute complaint. What you are calling the "right way" is actually according to Medicare and your insurance company the wrong way. If you don't like the way it is, PLEASE call your congressional representative and have this broken system fixed, and stop blaming your doctor for something he can't control. Many doctors have stopped, and about 40% of doctors (including me) are considering doing away with accepting insurance altogether because we hate being blamed for and having to deal with exactly what you are complaining about. By the way, it costs me about $50,000 per year to collect money from your insurance company, who tries to find all kinds of ways not to pay me for the work I do.

its not the government

stop blaming the government.

doctor billing

You can easily protect yourself from surprise bills from any health care provider. We did a segment on this on our TV program last week. There is a form that you can carry with you when you have medical treatment. It's right at the bottom of my column on this page of our site:

Very helpful comment -- Thank you, Kate

Very helpful comment and info. This is one way to take control and solve the overcharging problem. So people can see it, here is the form:

Dear Healthcare provider,

As a condition of my accepting any medical exam, treatment or service approval of all charges must be obtained from me in writing prior to commitment. Any charges not approved by me prior to commitment will not be payable. This notice is binding. Service may not be denied on the basis of this request. This is not a dictate of the services and methods used or applied by you or your facility, it is a requirement that I be informed of all costs prior to commitment and to be allowed control of the costs and obligations that may be demanded of me. Notice to agent is notice to principal, notice to principal is notice to agent.

Thank you,




Anne Landman

I would not accept this

If a patient came in carrying this form, I would not take them as a patient. Again, I do not decide on fees, Medicare and Insurance Companies do.

my doctor dumped me !

After 13 years with the same doctor I got dumped. It was not concerning billing. Im not sure what the real reason was I can only speculate. I have always had chronic headaches; but I had no problem with my doctor until I needed fmla papers filled out. She seemed not to want to but she did. 1or 2 days amonth.for migraine so that my job was protected thanks to Clinton's Family Medical Leave Act. Anyone with a serious medical condition and been on your job 1 year and 1250 hrs. I have now been at my job 23yrs. Ive always had chronic pain all through my body. It is "said" I have Fibromyalgia. In the past 4 years ( in addition to depression ) I have gotten worse and worse. Anxiety came and went sleep trouble. I would complain to my doctor. She did help me, but never gave me the clear clinical diagnosis nor sent me to someone who would. I began to feel she was not on my side in life and I guess I was under the misconception that my doctor should care about me and my health and well being. Well last year something came over me and my legs wouldnt work. They felt heavy and wouldnt move. It took great effort and terrible pain to walk. I called and called to get in to my doctor as I felt if you cant walk something is wrong! Especially if youve always been a very fast walker! I finally got in to see a nurse practitioner. A new one. Let's call her Jane. Well I told Jane all my symptoms and how bad my legs hurt how helpless I felt how bad I hurt and she just told me "well, were not going to give you anything."Like I was there looking for drugs. I was crushed. If you cant go to your doctor for help what do you do? I got blown off. I got so depressed and my legs got so bad I couldnt get out of bed except to drag myself to the bathroom etc. I keep calling to get an appointment with the DOCTOR. I finally got an appointment I could make. My job hours have my life schedule a mess. I work from 3pm to 2:30 am Mon thru Thurs. Off on Fri unless there is mandated overtime. Well my doctor put me on the anti deressant EfferER and back on Klonipin and I got better. I also ask her for a mri as my symptoms were like MS a friend said .I was terrified. The results were negative. Well since then my fatigue headaches and PAIN in my body hit an all new limit. I could barely move somedays Almost everyday. Im 54 so I thought menopause hormonal imbalances may be a point. To end this long story, i needed fmla papers filled out again. The company makes us renew them every year even in the most chronic of cases such as HIV. which is stupid cuz a contion is a condition in certian cases. The papers were in that office "lost" and ignored for a week. The Nurse at work wanted me to get more time on there this time as the 1or 2 days didnt always cover me. I think she didnt like that and the fact that I was online researching pain clinics near me and pain specialist til I found one I thought was of reasonable distance and covered on my plan. The only referral she ever reluntantly gave me was far away and I cant do mornings as I have to sleep. And It was another doctor from INDIA like her. Anyway i left the name and numbers of the doctors and pain clinic that would serve me best with the ans machine and phone nurse. They said they put it all in her mailbox. Well, the next day I got a letter that I was being dropped due to lack of compliance and bad doctor patient relationship. After 13yrs Im non compliant? after 13 yrs Idont have a 'good relationship" with my doctor? and it is my fault? It was when I became more aggressive and pro-active toward my own care that she got insulted and dumped me. Im felt she could have talked to me after 13 years of taking my money. It hurt and Im very very scared now. If you cant count on your doctor what can you do? so now what? She didnt care about me and if we had a bad relationship it was because of her I was always honest and open with her . i just tried to get the help I needed.


Your problem is called Somatization. It used to be called Psychosomatic. This is physical (very real, by the way) symptoms that are caused by anxiety or depression. The reason you were dropped is because patients with this problem are depressing, frustrating patients to deal with. Doctors get depressed when there is little they can do for their patients, and then they sometimes get angry or frustrated at the patient for making them depressed. The staff also complain because they usually have to take extraordinary measures to answer calls, reschedule appointments, etc. Patients like this take an unusual amount of time in the office also because it is difficult to convince the patient that their emotions are causing their physical symptoms. This is why your physician dropped you. I am not defending her, but I am actually surprised your doctor continued seeing you as long as she did. All doctors like to see patients that we can make better. That is what we went to school for, after all.