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.


I had a similar thing happen at the dentist. After the dental hygenist does all the work, the dentist comes in and pokes around for less than a minute. One day the dental hygenist said, "Do you want to see the dentist?" And I asked if I had a choice. She said that it costs an extra $39 for the dentist to come in and I of course declined. The rule of thumb is the patient has to see the dentist once a year. I go to the dentist every 4 months. I had gone several times before they told me about that little out. Thanks for your very informative post.

Since there is no longer a relationship to destroy and since it is such common practice (in South Africa where I live similar items pop up regularly) i would have thought that there is at least a contractual or financial challenge. Certainly there is an ethical challenge to be made. Although our legal systems differ, they all have some basic things in common. One of these is not having been informed before hand that certain things are extra and can be charged for. Supposing this had arisen in a contract over financing the purchase of a car and that some of the charges were hiden, undisclosed and appeared only when the gun is at your head and payment is being extracted. Adding insult to injury, an item which seemed an obvious part of the car, was called an "extra fitted luxry" (light fitting, or gear lever) and was part of the charging system. Ethically, The American Medical Association has a useful, if heavy, publication: "Code of Medical Ethics of the AMA" and it is the opinions and annotations (2008 - 2009 edition) of their council on ethical and judicial affairsl. these types of issues arise regularly and differing ways -- one of which is part of the informed consent procedure, another would arise out of a contract between the doctor and insurer, etc. i use this reference book regularly in some bioethical studies I am doing, and as a journalist too, I have some knowledge of how health insurers work (we appeared to have learned from you!) It is indeed difficult to challenge doctors -- i do it all the time but have learned to preface it with items like: "You're not hampered by a bloated ego are you? There's something I wanted to ask....." But there are many who jump no matter what is being asked or how. As I was about to have an epidural anaesthetic for the birth of my daughter, I asked of the anaesthetist, with nothing particular in mind: "what are your qualifications for this type of procedure?" Journalists ask those questions and I didn't know the anaesthetist. He was very angry and about to plunge a needle into my spine. Often however, the type of phenomenon you encountered begins with the insurance company which has stipulated what it will pay for and what rate. To maximise that, the "added extras" are slipped in. Not even a bank would easily get away with slipping in an item disguised in such as a way as it is not distinguishable from the rest of the transaction, but then charging more for it without any warning. I am often called anti-doctor and I no longer care. As the daughter of a doctor and who sees doctors at the drop of a bump, what I really hate are crooks. Some doctors unfortunately allow themselves to get tarred with that brush by behaving peculiarly when an insured patient pops in (worse when an uninsured one comes in) others bring it upon themselves with their belief in their own god-like status. of course some are crooks. But overwhelmingly, the kind of behaviour exhibited by the doctor described in the article, will have started with restrictions from insurance companies and is then mixed with a slightly inadequate ability to deal with it all openly with patients. And it need not be the insurance company of the author -- it develops over time and through many insurers and becomes ingrained. A letter to the doctor dwelling on her dubious ethics backed up with research from the AMA's book and offering her the golden opportunity to be judged by her peers in the AMA, may at least make her less likely to do it to anybody else. This business of firing patients I know happens in the USA -- but it doesn't happen in South Africa (too greedy to fire them). But my gut feel is that when it is because the doctor misbehaved and won't face a challenge, the decision of the doctor will constitute some kind of malpractice. By the way, that nice hipocratic oath (which is also in the book) always starts with something that amounts to "do no harm" and then specifies a number of other injunctions. this doctor has done harm not to mention some of the other problematic areas. But what I can't understand is why her identity is shielded. What doctors really don't want is bad publicity about their professional conduct.

After and ordeal like that, I can see why a patient would not trust the doctor--any medical intervention could be seen as a cash grab. Maybe doctors should have meters on the wall as they used to in the UK for gas and you put in as many coins as you can afford. As an American who has lived in Canada 20 years, I can't emphasize enough how nice it is to have your medical care disconnected from money. (the Canucks probably swing too far the other way, not minding how much they cost the system). I remember the first time I saw a doc and wasn't on the Ontario insurnance, they had to charge me and felt terribly for accepting a $30 check! I hope that we can shave a little bit of the profit motive out of health care in the US--maybe doctors should be paid if patients reach good blood pressure, health weight, and vitamin-enriched diets. amy cross women make news

The issues raised by the anecdote cited are quite complex. The doctor in question was a primary care physician, and PCPs are an endangered species. PCPs earn less than half the income of specialists, work as much or more, and have more bureaucratic hassles. Burnout is rampant. About half of our PCPs (150,000) plan to retire or cut back on their practices in the next three years. None of this justifies a $100 charge for a 1 minute throat evaluation or dumping a patient for challenging the bill. The first chapter of a preliminary draft of my book, Physician Managed Care-Universal Coverage Now with Free Market Health Care Reform, addresses the crisis in primary care:

My doctor informed me that if I wanted to remain his patient I had to start paying a $100.00 a month whether I saw him or not. (And this did not include the copayment I had to pay if I did see him.) His argument was he could spend more time with me and see me when I was in the hospital. Yeah, right like he ever did any of that. He just found a way he could get more money with less...I call them rip-off artists...

I dropped something on my foot and after a week of pain went to a doctor recommended by my primary care physician. After an X-ray, and a two minute exam I was sent home with a plastic and foam boot and told to stay off the foot for six weeks due to a slight stress fracture. The bill for that visit was over $900. When I complained about the excessive costs the doctor told me he had to charge that much to get paid enough from the insurance company. He said the boot cost him a lot and he had to mark it up. I found the boot online for $75 - the doctor charged $500. Most of the cost of that visit came out of my pocket because of the deductible. In the future I will always ask the costs before any service is provided at a doctor's office. This is one example of why our health care costs are out of control and we need a single payer option.

Yes, the doctors' fees are inflated. By the way, if you came to my office, I would have given you a prescription for the boot because insurance companies will not pay anything - not a single dime - for it. This is something your doctor gave you for free and paid for it himself, and here you are complaining about it! My fees are similar. The reason is the Insurance companies. My most onerous contract says that they will pay 120% of the Medicare fee schedule from 4 years ago (all insurance contracts are based on Medicare fees) -OR- they will pay one third of the bill, whichever is less. That means that I have to charge 360% (more than 3 times) what the Medicare fee schedule is in order to get the maximum fee from this insurance. So that is the basis of my fee. I NEVER get paid this, and I don't expect to. I have a self-pay fee rate that is much lower than my overall charge. But patients ask me all the time why my fee is so high. Now you know.

Do you not read? "Most of the cost of that visit came out of my pocket because of the deductible." The patient paid the bulk of the $900 fee, $500 of which was the boot you say the doctor gave for "free." Had the patient purchased the boot on their own, it would have cost $75. The provider billed more than SIX times what the boot was worth. "And here you are complaining about it." I don't know the original poster, but i sure would complain too!