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.

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.


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.

First, call your state Capitol and get the main number for the Department of insurance reporting all parties, doctor, dentist and insurance companies. Provide any authorizations you have in writing from each provider. The dental may be under a different policy than the medical and each should have some arbitration remedy but trigger it with the governing agency for insurance in your state.

Your concern is commended but as far as contacting the departments you recommended I can tell you from experience they are useless. They will tell you they dont have enough funding and there is nothing they can do-that a doctor can charge whatever they want. They told me to contact an attorney . The attorney said it wold cost me more to go after them then what I would get. They win.-for now. Nice to know there is a special place in hell for doctors like that.

My Dr bills for time. 20 min. Or 40 min. She should not have charged you. Send her a letter stating you fired HER. The nerve for her to drop you.

Billing doesn't work by time and if your doctor is doing this then that is wrong.

I came across this article when I was searching for information about how much time doctors have to bill a patient. I went to an ObGyn for a regular visit and then a follow-up, which were supposed to be fully covered and I was not expected to pay anything, according to the assistant. After the visits everything was supposed to be "all set", according to the doctor office, but later I see the new claim on the website of the insurance provider stating $2X,XXX that I may expect to pay. I contacted the doctor office and they tried to explain to me that this amount would be written off by them. But what proof could I ask to make sure they will never send me a bill for this? I was given a sheet of paper with two hand-written words "no balance", a date and a stamp, but is it enough to be sure it will not come back to me later?

While I see that people blame the doctors. In reality, the real culprits are YOUR insurance companies. In reality, doctors base their fees and codes based on what the insurances allow and require. A physical exam is designed to diagnose sickness or medical conditions for which patients are not aware of. The doctor gets paid to find this information out. The doctor is also required to report this information to the insurance company. As consumers of medical care we feel like victims, yet in reality it is our own fault. We should and in fact are responsible for being aware of our insurance benefits and how insurance works. Our policies are so extensive that a doctor can spend more than a day explaining all of our benefits. For this reason, many offices have signs warning us to REMEMBER that we are responsible for being aware of our benefits. The doctor in this story did nothing wrong. In reality, we should be more concerned with insurance companies controlling our healthcare costs.

I rarely go to a Doc but i got sick with this terrible flu one year and had to go to the Doc, a PCP. At the time I did not had insurance. I got charged $75 dollars, for the first visit and then another $75 dollars for a second visit. One year after I got sick again so, I went to the same PCP. I now had insurance that has a deductible of $6000, so I knew I would be paying for all of it. So, between doctor appointment, vitals with nurse and front desk bureaucracy, I spent exactly 36 minutes. Later, for my surprise I got charged for that sick visit $280 dollars. I called the billing dept and asked that I wanted to be recharge at a lower price. Explained what happen the previous times. They responded that the Ins. set the prices. I said then I need a new PCP. They said that they have the lower prices in the area that would not be smart. I said you just told the Ins. set the prices, how come you have the lower prices? I know you can negotiate a better price. No answer. Doc hide behind Ins.

I have a HSA deductible account. When I visited a dermitologist, the receptionist said if I pay cash they will charge me $80 copay. But if I decided to use my insurance, they have no idea how much they will bill them. I ended up paying MORE than $80 WITH insurance because the dermitogist billed my insurance triple of what they would charge for cash. The mdical system in the country is a joke. All doctors' assistants are morons. They don't care for you like a patient or even a human being, rather a credit card.

If someone comes in for a "regular checkup", that is a specifically billed item. If someone comes in with a complaint, that is a different specifically billed item. Whether a complaint is voiced after a well visit in response to "You having a problem with anything?" or the patient vocalizes it outright, in today's litigious society, it works the same. In the case presented, you have made the doctor responsible for whatever may be happening with your throat. The add-on "lump in the throat" complaint would definitely not be minimized if (Lord forbid !) a developing mass was found later. The extra service charged represents his acceptance of responsibility for the new complaint.