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.


This notion that "the doctors did not choose or design this system" is completely ludicrous! No one will ever be able to justify to me the enormous amount doctors charge for their services. My son recently had to be seen by a wound care clinic for ongoing treatment. This was done through a hospital and when the bills started coming in, I was sick! Not just from the charges that incurred from the hospital but I was also being charged, essentially, twice because I received a bill from the doctor that we saw that day in addition to the bill I got from the hospital. The bill included an office visit charge and a charge for the servives provided! How can this be right? Being charged as if we went to two different facilities that day and receive two different services. Now, if you can tell me that the government or medicare says that is the way doctors have to charge, I would have to disagree! Who are the ones that stand to gain the most from this kind of practice? The governmen? Medicare? Or the doctors? Ya, that's right, the doctors. So, go right on crying to all of us "laymen" about how much it cost you to run your business and keep on charging us in upwords of hundereds of dollars per minute. Yes, I said per minute because that is the amount of time most of us are with a doctor. On to the part about being charged two fees when we ask a question about our health when we are at the doctors office for a physcial exam. What an oxymoron. Sometimes the question or concern is not an "acute complaint" but something that jars our memories when it is initiated by a doctor's question "do you have any other questions or concerns". Here is an idea, instead of telling us with your own words how the governement is in control of the amount you doctors charge, you could share with us some resourses we can explore to educate ourselves on how the cost of medical treatment has been so grossly taken advantage of!

That's crazy. If this is the case then you should only be billed for the "2nd visit" if the your question requires more than 2-5 minutes, leads to further examination/procedures (x-rays, tests), or an issue is found.

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.

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.

I went to my dermatologist in nyc for adult acne - this was a follow up visit to get new prescriptions. The doctor wrote me 2 Rx and scraped some blackheads from my nose with a tool you can buy at the drug store. The office billed my insurance $400 for the visit and $600 for acne surgery. I paid a $50 co-pay, and the insurance company applied the bill against my deductible, after adjusting the charges signifcantly lower with the explanation "discount". Bottom line, I received a bill for an additonal $84. I refuse to pay an additional amount on the principle that no surgery was performed. I was not told that scraping my nose would cost me more than the co-pay for an office visit - I wasn't even asked if I wanted the service, he just did it! I called the office and explained I thought the additional charge was unwarranted, and the billing clerk told me "we bill anything acne related as surgery.." So why not bill $10,000 for dermabrasion if you're looking to milk your patients/insurance companies? I'm going to call back or send a polite letter saying I disagree with the charge and believe my standard co-pay is reasonable for the services perfomed. What do you think? Will they send my bill to collection for the $84 balance?

Our insurance allows one visit per year with a $20 co-pay. If the visit is coded with a medical diagnosis instead of as a routine checkup, our insurance won't cover it. Our long time physician recently hired a new insurance clerk and she refuses to code with anything other than a medical diagnosis. To make things worse, the office has recently changed policies requiring payment up front for the office visit ($150) instead of just the co-pay and waiting for the claim to clear to pay any balance. My new American healthcare plan is to stop taking the medication I have been prescribed and wait until something happens that requires emergency care (no, not using the ER as a physician's office...something truly dire). Our insurance will cover that, less a $50 deductible. We simply cannot afford "routine care" any more.

Anne, This is an excellent post. I like doctors to, after all they help us stay healthy. However doctors should not be able to charge whatever they want. Many people assume it's all the insurance companies fault. But is it fair for one doctor to charge $100 for a general exam, and another doctor in the same city to charge $300 for the exact same service? That is why most insurance companies research the average fee charge in an area for that service and may only pay for the average fee charged. Doctors could charge a lot less and still make plenty of money. If government regulated what doctors can charge it would cut cost for insurance companies, and employers and the savings would be past on to the consumer. I wish people would spread the awareness. I am not out to defend insurance companies. However consumers need to know the truth. The health care crisis in America is not all the insurance companies fault.

And repeating the things you are saying clouds the picture of health care costs. Doctors cannot charge anything they want. The doctor who charges $100 gets paid exactly the same as the doctor who charges $300 for the same service because insurance companies set the amount the physician gets paid, not the rate the physician charges. You said, "...most insurance companies research the average fee charge[sic] in an area for that service and may only pay for the average fee charged..." You are partially right - ALL insurance companies know EXACTLY what the other physicians in the area get paid because they determine what they get paid! And, it is ALWAYS regulated by the prices that the government sets, because all contracts are based on Medicare reimbursement. I now have a solo practice, but I was employed by a large group before. The CEO who only had an MBA made 3 times what the doctors made. The CEO of the hospital where I see my patients makes 10 times what I make, and he only has an MBA. If I didn't like practicing medicine and taking care of my patients, I would go back to school and make a LOT more money!

As a primary care doctor I sympathize. The response from the doc was heavy handed but appropiate. Day in, day out I have patients that mention the dreaded "By the way" as we are concluding our visit. Or the similar "While I am here..." "My wife says I have to mention...." at the end of the visit. Many of these are addressed in a professional manner but some...! Imagine going to your mechanic for an oil change (routine maintainence) and while the car is on the lift say hey while your in there check the brakes -They make a horrible sound (problem based symptom). Ethically you don't want anyone to get hurt so you do the service and CHARGE for it. You don't give it away. I'm always pissed at the labor change for the mechanic, washer repair man (Really 60 min minimum for service call) but I accept that I am not trained to do these things or do them right. As a physician my skill is my ability to sort out illness/disease and treat as needed or possible. If you ask me at a cookout to look at something or about your particular case then you are stealing my livelihood. Kind of. FYI- My guess is that the writer was not discharged for this one occurance. Many of my pain in the ass patients are tolerated for years before a straw breaks the camel's back. You just iced the cake that day. I will try this new concept on my employees first. "SInce you are already here I am going to have you work an extra hour and I don't want to pay you any extra for it." "It would be unethical for you to leave and deny care to my patients." I will also ask my dentist while he is pulling my tooth that he go ahead and pull the other one for the same charge and that then point out to him it is is unethical to charge me more for doing so. In fairness I will put a fresh fish market white board out front to advertise my daily rates. Sore throat $40, Physical exam $80, Fibromyalgia $750. Listening to all your whining about health care costs, drug cost, gas prices-still seeing you (beyond your scheduled time)-foregoing a paycheck when my office can't meet payroll---Priceless. No really, no price-It was probably given to you by me for free.