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

I went in for a annual physical covered 100% by my insurance and then got hit with surprise charges. Apparently when the doctor asked if I wanted an STD screen, that was not considered what is usual and customary to a annual physical, so I got charged for those labs. The physician should know what is in the scope of a physical, more so than the patient, so if they offer any service beyond such they need to be transparent and provide a disclaimer that it is not part of a physical and could incur extra charges. After all what other services besides health care does not give you notice. If you take your car in for service and they find another issue or offer another service, they quote you the additional cost.

I was charged $95 by Loyola University Medical Center, outpatient clinic in Oakbrook Terrace, IL to sit in an exam room and talk to the doctor!!!!!! I didn't even sit on the exam table! The doctor billed me for his time which I have no problem with however $95 to sit down!!! When I called to question the charge I was told it was for the use of the room and the supplies in the room. I told billing that all I did was sit in the chair and talk to the DR. their only response was "you should have gotten a letter we sent to patients last September,2013 telling you we were going to start charging for this!" Next they will be billing to sit in the waiting room!!! I THINK A CHARGE LIKE THIS IS MORALLY WRONG AND AMOUNTS TO NOTHING MORE THAT ROBBERY! LOYOLA SHOULD BE ASHAMED OF THEMSELVES!

Happens all the time. You should see what goes on with oncologists who just ask questions during exams, never lay a hand on the patient and then charge for a Level 5 exam. Here's something interesting copied from a site called something like "Coding Pearls " (of Wisdom-haha) that tells doctors they GET PAID FOR WHAT THEY DOCUMENT AND NOT WHAT THEY DO! This is called the "Level V Caveat): (Top) "Remember, you don't get reimbursed for what you do, you get paid for what you document! A frequent deficiency area for down coding a Level 5 to 4 is the ROS. Level 4 requires 2 - 9 systems with Level 5 requiring 10+. Listing of pertinent positives and/or negatives with the statement 'all other ROS negative' meets Level 5 requirements."

My doc told me I needed an ultrasound so she sent me to a specialist. I too was just sitting on the chair with no exam done. He walks in and asks what the problem is and I told him briefly(took about 5 seconds) He said I needed an ultra sound. Charged me $350. Guess he needed the money to play a round of golf. Bet he tips his caddy a shiny new dime!

I questioned this too for my husband's visit. We were quoted what they verified with insurance and then for the follow up visit I was told there was a balance due from the original visit to the specialist. He literally spent less than 15 mins with us. His office told me he had indicated that was longer than a normal first visit on the paperwork for the insurance and now I have to come up with an extra 88 dollars in addition to 105 for the follow up to find out what is wrong with him ( after we shelled out 1200 for an MRI) What can I do?

My wife was having to do a dental procedure and the doctor office told us that it was covered 100%. The dentist also told us that it was a necessary procedure and she may have complications if we decide not to get this done. We had the procedure and few weeks later I got a letter from insurance that the claim was declined because the dentist from insurance company didn't see it as a necessary procedure. A week later I got the bill from the dentist and their staff told me that they considered it as a necessary procedure but the insurance is not paying so I have to pay. I have done my research and the conclusion is that there is nothing I can do in this situation except to pay the bill. Just like the writer, I feel like I was used like an ATM and my doctor's office tricked me into having a procedure that wasn't necessary.

The bills will haunt you if you don't pay them and will end up on your credit report so long you will one day forget what they were. Legally as long as you pay every month, for as long as it takes, send a $10.00 check and save the cancelled checks. Don't do it online; make them stamp or sign the check to deposit. If you already own a home and never plan on buying another you don't pay anything, you will eventually be turned over to a credit agency. 1,2, 3 years later you have heard from 9-10 different collectors until one tells you they will settle with you for pennies on the dollar. You need to ask for it in writing and if they won't put it in writing that they will take it off your credit report then tell them no deal. The torment caused my some idiot is why they need to make a deal but if treatment was really needed and the service was performed, something should be paid. Always get it in writing what insurance will pay ahead of time. Emergency excluded obviously.

My husband went to the dentist and when he got there they asked him if he took his antibiotics. He was not prescribed any for that visit. The told me that their patients areEXPECTED to know they need them. They said they could supply them. I asked the cost and they would not tell me. They said they did not know. (they sure knew how much to bill for them) I asked them to call in the script to the pharmacy just minutes away and then the girl said they they only charge a little more than the pharmacy does-couple dollars more. i figured what the heck the get them a the dentists office. After the visit he got billed $16 for 4 pills. Walgreens would have charged him $1.09 a pill. Dentist was 4 times as much! . Dr Crook said the bill stays as is .That is their office policy. It is MY policy not to pay for fleece jobs.

My ob gyn, whom I am receiving prenatal care from recently attempted to charge me for an ultrasound which I didn't A. Ask for or B. Necessarily need. I also wasn't made aware of any charge for it and so I refused to pay. The nurse had asked the ultrasound tech to check the babies heartbeat. (It is routine to check the heartbeat, but not necessarily with the ultrasound equipment). Out of concern, and because she already had the equipment ready to use, the tech took it upon herself to check the fluids around the baby. (I'm 41 weeks pregnant.) the doctor walked in and began screaming at the tech in Russian but I understood the conversation. She was yelling that the insurance would not cover it and the tech answered her that it wasn't a big deal. The yelling continued in the hallway. When the doctor came in to check me, she told me I'd have to pay half the cost for the ultrasound. ($40) I flat out refused. But I did this not solely based on this particular situation but on the fact that the doctor had asked me several times throughout my pregnancy if I wanted treatments I'd have to pay for in cash. At one point she offered a herbal remedy to help the baby turn head down. She told me it was $100 and i would need to pay an extra $50 if it worked. I denied all these "additional" services because well, they just seemed like a scam artists ways to make extra cash. After refusing to pay, she replied okay, didn't offer any more information about the baby or scheduling another appointment or induction and walked out of the room. She then began screaming at all of her employees. It was the most ridiculous spectacle I've ever seen. I want to report her but I'm not sure how to go about it.

To address other peoples' comments, I understand that doctors bill way high to get the money they should from insurance. My dad is a doctor and when he worked in a hospital, they often billed really high for things they knew they could get covered by one person's insurance to make up for what they lost treating people who didn't have insurance and would never pay. Now, he has a private practice and does not accept insurance for the reasons others have already explained. Yes, it's a broken system, but doctors spend 8 years in med school and are clearly smarter than me, so they deserve to be paid. That being said, I don't get why doctors can't just tell you something is going to cost more?!! My doctor growing up was so great about this - I switched birth control pills a few times trying to find one I liked and every time she would say "we can try this one, but it is more expensive." I got my flu shots for free (which they offered) and my cholesterol checked (high cholesterol runs in my family) all included in my primary care visits. I just had blood work done with a new doctor and just got a bill for $1200. I mean.... if you're going to do something that costs freaking TWELVE HUNDRED DOLLARS don't you think you should freaking mention it??? It was a bunch of tests that had to be run by a lab, but how was I to guess that it would be so different from a cholesterol check. Seriously that much money can really affect peoples' lives. Why is it just not common practice to be like "I think we should run these tests, but they will cost you one month's rent" It should be my decision whether or not I want to pay that much for a precautionary test. So from here on out I will be that annoying patient asking "how much will that cost" every time the doctor mentions doing anything. It just seems unethical to me to not make patients aware of cost. No doctor can pretend they don't know that's important.

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