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.


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.

Oh! but you did design the system. It is called the AMA. They and their big bucks lobby and pay off politicians to benefit you not sick people. Medicare may lower their reimbursement fees but than you just jack your prices for people with private or no insurance. Our deductible goes up and we have to pay more out of pocket. ie and extra 250 to write a few scripts that takes you only one minute to write. But then your poo doesnt stink so I guess you are allowed to rip us off.

FYI I do come in for almost all these things. My greedy doctor charges me that extra 250 . That is 83 each script written for the medication I take for these health concerns.1/3 minute each at a total 1 minute. He has already checked my heart, lungs,and what ever else he checked during my wellness visit just less than a minute ago so he does not have do do it twice,but charges like he did. They call it a med check.Really?? What exactly did he check since an exam was already performed. All he did was write the damned scripts. What justifies this? Oh! I forgot-his poo doesnt stink. Maybe patients should hold a strike in front of their doctors offices to shame you. I am in if someone should ever have the you know what to arrange one. Or better yet why doesnt just one doctor from every office in the country march at their capital building to change things to better their patients if you really care so much about us. Put your time where your mouth is.

I can only guess why things went as they did in this patient's encounter. A number of motivations come to mind which are too numerous to describe here. She points out, however something I have noted which is that some of my colleagues have become experts at gaming a system that rewards for doing more. One sign of a person's shift from compassionate care is a doc's shift in everyday conversation from care issues to material things or money-making schemes. A system that rewards one for the skill in handling cases, outcomes, interpersonal skills and all the things desired in a "good doctor" would be ideal but hard to develop. Attempts are being made to incorporate this but with little data to support the metrics so it is a little scary for the average doc who just wants to give good care. Best, I think, would be to support and incorporate the best models out there, such as at the Cleveland Clinic where doctors are salaried and not paid by production and number of procedures. I am in emergency doctor. I don't do "wallet biopsies" and can't (and don't want to) choose my patients. I like that but is is not for everyone. Most emergency docs burn out and retire or move to something else by my age. My heart goes out for patients with limited means and I will game the system to save them a few bucks. Universal healthcare would solve that problem. Obamacare is only a start. It has deep flaws and will get bad publicity but keep aware of developments and lobby your representatives to improve it. Be aware that corporate interests are always trying to improve their bottom lines so look at where their lobbying money goes and press for alternatives. It's tiring but eternal vigilance is more important now than ever.

Finally,a doctor with a heart. Thank you. I do have to make a comment about the Cleveland Clinic. although the doctors are on salary it is still a for profit business. (my doctor is on salary) Their prices are high because they have to reward their CEOs the mega bucks whose primary concern is PROFIT. I think you already know that. Only the AMA and doctors can make the changes needed. We,as patients,are pee ons.I do not have my own lobby. If you all ever decide to really do something about this,Im in. Just give me a sign to carry! WE NEED MORE DOCTORS LIKE YOU !!!

Yes, there needs to be a "real" regulation on what doctors charge for an office visit and the time allowed for that visit specific to the visit. There was a time that seeing a doctor did not result in just a specific issue but the doctor would entertain a question that might arise during the visit regarding another concern. And at one time you were seen for several things at the same time. Now they want you to schedule for every single thing separately. And if you are uninsured the doctors are charging huge amounts for a visit. How does $300.00 sound for a single office visit. Plus they are requesting cash. Does that lead one to believe they are hiding income? It is out of control. They have put themselves in financial ruin buying large facilities while the public can not afford insurance or visits and have decided food and shelter is more important than seeing a doctor or taking meds. Meds are also out of control. The pharmacies are loaded with scripts. No doubt the doctors get a kickback form prescriptions which should be illegal plain and simple. It is a conflict of interest without a doubt. The doctors are just waiting for the babyboomers to roll in to line their pockets across the next 15-20 years. Is anyone paying attention to this issue. Sad state of affairs for sure.

Two weeks after a friend went to the ER for a migraine and other symptoms, she had her annual physical. The doctor enters the exam room reading from the ER notes and asks how is she feeling? Any pain? The patient says she is fine; there are no symptoms since the ER visit. When she gets the bill, the doctor had added a separate charge for this "follow up exam." It was never requested by the patient and there was zero notice that it would incur an additional charge. When she complained, the doctor's response (through the billing office) was she performed the procedure and is entitled to be paid. This is consumer fraud. Imagine the doctor bringing his car for an oil change and the service writer says, "how are the new brakes we put on last time you were here?" The doctor says "fine" but is charged $25 for a "follow up service check." He would never stand for it. Medical costs will never be controlled if patients don't know the real cost and if physicians are not required to disclose them -- a standard practice in any other business. This practice is a complete fraud on the patient, on the consumer and on the health insurance companies. A smart state attorney general or a class action lawyer should take this on. Doctors are entitled to be paid for services rendered, but they are not entitled to be deceptive in their business practices.

I came across this site while researching what to do when a cash pay patient left after being seen and told the front desk sorry we don’t have any money and can’t pay you. No offer to make payment arrangements, just left after the doctor spent over an hour with them due to several complex issues. This is the second time I am responding to a comment. Stop thinking that your preventative exam is all encompassing. Read your benefit manual. Go online and look at your insurance company policies. Educate yourself. If you feel that the doctor is wrong to document and bill correctly then appeal it with your insurance company. I would hope that you got all your facts before you start accusing someone of fraud.

No, Lisa, stop hiding all the doctors doing billing fraud, as also refusing to diagnose. Halls time is up, as patients are becoming aware.