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

Insurance 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

examination day surpriseMy 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.

doctor taking moneyOn 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.

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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.

Comments

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.

My insurance premium goes up every year like clockwork. I guess my insurance company is altruistic and truly cares about me and is looking out for my health. I mean, if the premium ever went down just once, I might have a heart attack.

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

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.

Is there any written documentation stating what all of you doctors who have posted about not being in control of what you charge? I understand that insurance companies get to tell you what they will pay and tell you to "adjust" the price per service, but, what I beleive you do have control over is not, in turn, billing the patient for the difference in what the insurance company finds too high of a charge. Please advise as to any resources that back your claim that the governement is in control of the charges and you are not.

I guess my question would be why do you charge people for things without disclosing that there will be an extra fee associated with it? You want to charge for answering a queston, fine. I dont like it but fine. But the real issue is you dont even give a choice. You dont say "Hey I can answer your questions but it will cost you "x" amount. No you just answer and charge, Full disclosure on what things cost BEFORE you treat us would be fine but you dont. You ask seemingly innocent questions knowing full well youl bill us if we ask them but never tell us. I went for a physical, my doc checked my ears and said they had wax in them. He asked if I wanted him to clean them out. I said sure. Went to pay and my co-pay was double because he cleaned my ears. He squirted water in my ears. That's it. I can do that without going to medical school and if he had told me he would double charge me for it I would have said no. The deception is the issue. Be up front and people wouldnt mind. But when you take away our choice in the matter and bill us after the fact without letting us know there will be additional charges, well thats just dishonest. Please try and justify that.

If the patient has to fear an additional charge in order to ask a question about his/her health, how is that beneficial? Your are supposed to be a healer. I understand that there are limits and some people will abuse the relationship. The car mechanic analogy that is being so freely used is disturbing. I am a human being; not a car.

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