Doctor’s note? It might cost you

Special to The Times

When Jill Wolfson called the psychiatrist last year for a prescription refill for her son, she had an unpleasant surprise. Up until then, the over-the-phone refill had been free. This time, she was charged by her doctor for the service, to the tune of $25.

“I was really astounded,” says Wolfson, of Santa Cruz, whose son had long been seeing this psychiatrist for attention deficit disorder. “We go in for regular checkups to get his meds looked at, so it’s not like we call in for refills without ever seeing him. It just seems like it should be part of the service when you’re being charged $100 an hour.”

Ching, ching! Doctors -- particularly primary care doctors -- are increasingly billing for services that patients have long expected to get gratis: prescription refills, photocopies of medical records, phone consultations, family medical leave forms, medical disability forms, waivers of insurance premiums, waivers for handicapped plates.

Automotive forms. And life insurance premium forms.


Travel insurance forms.

And now, e-mail responses.

The practice, almost unheard of five years ago, has disgruntled some patients and is starting to come to the attention of consumer advocates, who denounce it as one more sign of a broken-down medical system.

“It shows that healthcare is like any other enterprise: It is revenue-driven,” says Arthur Levin, director of the New York City-based Center for Medical Consumers. “The system is moving further and further away from being a public good to one in which the physicians are mere shopkeepers. How many times can they ring up the register?”


Even many physicians admit being uneasy about what they themselves refer to as “nickel-and-diming.” And those who have so far bucked the trend suggest it is only a matter of time before they join the crowd.

“We think about it a lot,” says Dr. Yul Ejnes, an internist in group practice in Cranston, R.I. So far, he says, “We’ve chosen not to do it, for the same reason we don’t do a lot of things: We don’t want to offend our patients.”

But many doctors see the practice as a necessary evil in times of increased business costs, flat incomes and declining reimbursement from insurance companies -- and the lack of a way to bill those companies for services that don’t involve face-to-face patient visits.

“In the old days, we just did it, it was part of doing business and doctors would absorb the cost,” says Dr. Richard Lander, a New Jersey pediatrician who currently charges $5 for school, camp or athletic participation forms. “But in today’s climate with so much paperwork involved, doctors feel they can no longer give services for free.”

Such “administrative surcharges” have been officially endorsed by several large medical organizations, including the American Medical Assn.

Lander recalls the reaction when he first started asking for the fee five years ago. “People were astonished. They were incensed. I had a few patients who left my practice,” he says.

But whatever the initial sticker shock, it eventually wears off once patients realize they don’t have a say in the matter. Schools increasingly require a doctor’s release, and many sports activities won’t allow participation without one. The consumer, in a nutshell, has no choice.

Patients pick up the tab


The trend goes far beyond filling out school forms. These days, some doctors refuse to write refills without seeing their patients in the office -- because that way, it’s a billable expense.

Although it is illegal, many doctors around the country now require their Medicare patients come in for an office visit if they want help filing an appeal in response to the new federal medication program, says Tatiana Fassieux, board chairwoman for California Health Advocates, a nonprofit association that tackles Medicare issues in California.

“What happens then is that Medicare gets charged for the office visit,” Fassieux says. “And that’s because physicians believe they are not getting sufficient reimbursement to do all the work they need to do to satisfy the Part D idiosyncrasies.”

Other physicians, notably pediatricians, charge patients for after-hours calls, passing on the $15 or $20 per call that they’re billed by the answering service.

And some physicians have come together to create official systems to bill clients for e-mail consultations. Medem, a San Francisco-based online service developed by several medical societies, including the American Medical Assn. and the American Academy of Pediatrics, incorporates a payment plan for e-mail consultations, regularly used by about 10,000 physicians around the country. The average charge per e-mail is $20.

“Typically, patients are so thrilled to have access to the doctor that they’re fine with the [e-mail] charge,” says Jason Best, a Medem spokesman.

Dentists, as well as doctors, are expanding billed services.

“Just last week I had to pay a $10 fee for my daughter’s dentist to make a copy of a single bitewing X-ray,” says Amy Linn of Santa Fe, N.M. “I was switching dentists and needed to pick up her files to bring them to the new dentist. And they wouldn’t give me her X-ray unless I paid the 10 bucks. I thought that was kind of cheesy since I’d spent hundreds at that office over the years.”


Doctors defend this growing trend. “It’s a reflection of managing your office in a period of declining reimbursements,” says Dr. Edward Langston, an American Medical Assn. board member. In his family practice, based in Lafayette, Ind., he estimates that an administrative assistant spends five to 10 hours a week filling out forms.

Langston and others blame nickel-and-diming on a broken-down, outmoded system of healthcare that rewards physicians only when they have “some skin in the game,” meaning face time with the patient, says Dr. Daniel Sands, an assistant professor of medicine at Harvard Medical School.

“The only kind of healthcare that is valued [by insurers] is the care delivered in the office,” says Sands, who lectures on physician trends. For example, he says, doctors have been “giving away” care over the phone for years, unable to bill insurance for the time. Medical intervention by phone or e-mail, he says, is time-consuming, requires solid medical judgment, carries the usual malpractice risks -- and is completely uncompensated.

The consequence, he adds, is that a lot of doctors will not call patients back. “They figure, ‘If my staff can’t handle it, then the patient is either going to get better or else come in [to the office] and I’ll get paid for it,’ ” he says.

But that is often not an option for primary care doctors, who oversee chronic diseases -- diabetes, asthma, congestive heart failure and others -- that require immediate access and patient-doctor communication if hospital stays and emergency room visits are to be avoided.

“If a child with diabetes gets ill with diarrhea or flu, it can throw off the entire balance between insulin and sugar, and it’s not uncommon to get multiple phone calls in a single day,” says Dr. Sandy Melzer, a pediatrician at Children’s Hospital and Regional Medical Center in Seattle. “You want to know how he’s doing on the hour. His most recent blood sugar level. Is he throwing up? ‘Give him X units of this and call me back in half an hour.’ If you have a whole practice of these patients, you could spend your entire time on the phone.

“And if none of them come into the office, you don’t get a dime for all that telephone time.”

In fact, some doctors protest that they are the ones who are being nickel-and-dimed. Lander, whose pediatric practice is in the toniest part of New Jersey, still bristles at the memory of the parent who left her Mercedes running at the curb, carrying “a $10,000 Judith Lieber handbag,” and arguing with him over the fact that he had just charged her $2 to fill out a school form.

Most patients don’t sport $10,000 handbags, however, and for many, paying these new fees is a hardship.

“Even a $20 form has an impact on many lower and middle income patients who are on tight budgets,” says Anthony Wright, executive director of Health Access California, a nonprofit consumer advocacy coalition based in Sacramento. “Studies show that even a moderate increase in co-pays can have a significant impact on things like prescription drugs and prescribed treatments. So presumably, if you have to fill out a form for the kid to go to school, is the child then able to get the asthma medication he or she needs?”

Wright sees the new charges as part of a troubling pattern -- “part of this trend of more costs being borne by the individual, even if they’re insured.”

Insurers look at changes

Some insurance companies, as well as some major medical organizations, are working to change the trend.

Billing for e-mail consults, for example, is already underway. Last year, Blue Cross-Blue Shield of Florida began offering reimbursements to its doctors -- at an average rate of $30 or $40 per e-mail, with the patient picking up part of the cost through a co-payment. Cigna plans to start next year.

And several groups, like the American Academy of Pediatrics and American Academy of Family Physicians, are working on codes to allow them to more easily bill insurers for phone care.

“Codes have existed for years, but 98% of the time they’ve never been used,” says Lander, who is on an American Academy of Pediatrics committee reviewing billing. “In the past, the insurance company accrued all the benefit while the physicians bore the expense, took the risk and kept the patient out of the hospital and other expensive settings.

“The insurers obviously are very worried about it,” Lander says. “They worry that [doctors] will abuse it for trivial, two-minute phone calls. They want to make sure that everyone is using it legitimately, as an alternative to office visits.”