Most insurance plans allow for one free physical a year. But asking your doctor a "non-routine" question can turn that free physical into a costly office visit. Why doctors---and hospitals---need to practice informed financial consent.

So I want to tell you a story that happened to my wife, Lauren. It may not save you $1,000 tomorrow, but it’s surprising, infuriating, and it involves something we all deal with at some point: health care.

Two years ago October, Lauren was carving a jack-o-lantern with our son. She took a stab at the pumpkin, missed, and cut her finger to the bone. She needed stitches, no question.

We were fortunate to live nearby a recently-opened urgent care facility. For a sprained ankle, a persistent cough, or a few stitches, these places are amazing because they’re closer (and hours faster) than the emergency room.

The new doctor

Lauren drove herself and checked in with the receptionist. As they went over contact info and insurance, the receptionist asked “And who is your primary physician?”

Lauren gave her doctor’s name, and the clerk shook her head. “Nope. She’s gone.”

Lauren’s doctor closed her office and left the state without notifying patients or giving them their medical records. This was the first Lauren heard of it.

Ultimately, Lauren’s finger was fine. But upon learning that her doctor had vanished, she needed a new one.

Some months later, Lauren had back pain. She wanted a referral to physical therapy, which she’d found useful in the past. But in order for our insurance to cover it, she’d need a referral from her primary care physician. Problem was, she no longer had one.

Lauren easily found a new one – let’s call her Dr. Anna — through a large medical practice here in Maine. Figuring that it had been five years since she had a physical exam, Lauren took the opportunity to schedule one with her new doc.

A free physical exam?

Under our health insurance at the time, annual preventative care like physicals were covered 100 percent. Everything else was subject to a $3,000 deductible, meaning we had to pay full price for other care (the urgent care visit, sick doctor’s visits, lab tests, etc.) until we spent more than $3,000, exceeding our deductible. Being healthy, we never do. So the once-a-year free appointment is the one real perk our health insurance offered.

Lauren went to the appointment, which went fine. She liked her new doctor and found her much easier to talk to her than her old one. Lauren was healthy, and she scored the needed referral to physical therapy. All good so far.

Fast forward 45 days, when Lauren receives a bill from Dr. Anna’s office for around $150 for the date of her office visit.

We assumed they made a mistake.

We even double-checked our health insurance policy and confirmed that annual preventative-care visits were covered 100 percent.

So Lauren called the office.

Very politely, Lauren explained that she believed the bill was an error because the appointment was a physical and covered by insurance.

The billing rep put her on hold. Returning, she said “I checked on that, ma’am, but the visit is billed correctly. It shows here that you discussed non-routine issues.”

Let’s stop here for a minute to explain what’s happening.

Doctor’s offices limit what gets billed as preventative care. During her physical appointment, Lauren brought up her back pain. She and Dr. Anna talked about it for about three minutes, and Dr. Anna provided a referral to physical therapy.

But the office’s billing practice did not consider back pain preventative care.

So here’s what presumably happened: The doctor’s office bills the insurance company for the cost of the physical, which the insurance company pays for per our policy. But the office sends another bill – this one for a non-routine office visit – because Lauren asked the doctor about her back pain. The $150 bill falls on us because of our deductible. Ultimately, the doctor gets paid twice for the same visit.

Blacklisted

It’s not about the $150. We’re very fortunate to be financially secure and an unexpected $150 bill is not going to break the bank. We were also well aware that had Lauren not needed a physical, she would’ve scheduled the appointment anyway knowing what it would cost.

But learning that the medical practice would have the gall to double-bill like this was maddening.

So Lauren upped the ante. She wrote a letter describing what she felt was an unfair billing practice and asked the office (and the doctor) to review it.

A week later, she received a voicemail from the billing rep. When Lauren returned the call, the rep informed her that the office stood by their position – the bill was legitimate. The office did, ultimately write-off the bill for Lauren upon her complaint, but here’s the kicker: The rep told Lauren that Dr. Anna preferred that Lauren find another physician.

She was blacklisted! Branded “a difficult patient” for complaining about a legal but unquestionably dubious practice.

Double billing of physical exams not uncommon

Although Lauren and I were left befuddled by this seemingly outrageous practice, as we began to tell the story, we quickly learned we weren’t alone.

“Oh, yeah,” a friend said. “I went in for a physical, mentioned I was getting really bad headaches, and that was a bill.”

Search for “doctor’s office double billing” and other experiences abound. It’s hard to tell what exactly is covered during preventative care. Not much, so it seems.

The Affordable Care Act requires certain free preventative care for adults, women and children. They’re things like tobacco cessation, routine vaccines, and screening for depression. They include other screenings like mammograms as you get older. But for a young, healthy male, it is conceivable that the only things covered in a physical are:

  • Instructions to lose 10 pounds and quit smoking
  • A blood pressure check
  • An 8-question depression screening
  • A flu shot

If you’re having headaches, stomach pains, trouble sleeping, or anything else, expect to pony up.

An old problem

This practice of double billing at doctors’ offices has been around for a while. Although some would like to point the finger at the Affordable Care Act, what I’ve read suggests this ugly stepchild necessitated by a broken health insurance system goes way back.

Consumers don’t get enough from health insurance for what we pay. And yet, some doctors don’t get paid enough for what they do.

Take this article for doctors that actually explains how to get paid more for physical exams:

You can bill for both a problem-oriented visit and a physical by appending the -25 modifier to the problem-oriented visit, which indicates that the problem was a “separately identifiable” service.

I completely understand that doctors need to be adequately paid for their time, and primary care docs have the hardest time. It’s gotten to the point where it may not be economically viable to go into debt for medical school and become a family practice physician. That’s a problem.

However, bait-and-switch billing isn’t the answer.

At least tell us!

Some medical practices seem to be better than others at educating patients. At another doctor’s office, Lauren received a waiver to sign before going in for a preventative screening. The form indicated the potential costs if the screening revealed the need for additional tests or procedures.

That’s called informed consent. It’s an idea well-known to medical professionals: They must inform a patient of risks and get the patient’s consent before performing a procedure. But they don’t have to get a patient’s consent to the cost of that procedure. That needs to change.

I don’t expect us to solve to issue of doctor’s offices double billing. All I want to see is medical offices hand you an easy-to-read sheet explaining:

  • What your visit will cost
  • What’s covered in your visit
  • What additional costs may arise from this visit

I know that, under current conditions, even that is unlikely. Until then, know this: The “free” preventative services your insurance company offers you are likely a Trojan horse. Go see the doctor. Just don’t expect it to be free.

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About the author

Total Articles: 353
David Weliver is the founder of Money Under 30. He's a cited authority on personal finance and the unique money issues he faced during his first two decades as an adult. He lives in Maine with his wife and two children.

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14 comments
Jenny says:

This has happened to me more than once, even in the ER. I was billed for two ER visits! Anyway, from now on I must remember to tell them I am only paying for one, so don’t ask any questions. My teenage kid got a second bill for his physical for an unknown reason. By a PA!

Bertha Lansman says:

My doctor wanted me to see a gastroenterologist for a colonoscopy. He explained the procedure to me and gave me a referral. I followed through and scheduled the an appointment, and then went to pick up the solution that I needed to take the night before the procedure, then once again, the directions for taking the solution were explained to me by the pharmacist AND they were on the solution itself. Then a few days after, I received a call from someone at the gastroenterologist’s office who reviewed the appointment with me and explained what I needed to do to prepare for the procedure…this is at least the third time that the procedure has been explained to me by now. Days later, I am surprised to receive a bill for $124 from that office. I am confused because I have never been to their office or received services from them, so I call. I was told that I was being billed for a telemed call. I was sure it was a mistake because all that they did was give me instructions for the procedure. It was not a call for diagnosis or treatment, and I didn’t even make the call in the first place. I made a couple more calls to dispute the claim, but they just kept sending me the bill. I finally wrote a letter to their billing department, but they just sent the bill to collections and told me that the bill still stands. The amount of the bill is not going to break me, but I feel that I am being swindled, and I don’t know who to turn to. There has to be some kind of organization that regulates this kind of thing and what health practitioners can charge consumers.

Jean says:

This double billing is a real problem and I went in for my annual physical knowing from experience that doctors do this. The first time I questioned it was several years ago when I had the same discussion with the same provider two years in a row, received a bill the second year for an additional copay because of the discussion, and when I questioned the bill was told why there was the additional charge. This year I went in to a new provider knowing I would not bring up any additional concerns but did answer yes to a question the doctor asked. This caused her to discuss the yes answer. Lo and behold I look at the billing and it is for two codes, preventive and established. I have emailed both billing and the doctor as I did not bring anything up but answered the doctor’s questions. My next step If this isn’t resolved with the clinic will be to contact the insurance and the state to file a complaint. Next time I go in for a physical I will be clear that I am there only for preventive care and that they are not to ask me anything that will result in additional billing codes. This certainly seems like a way to get additional money out of patients and with high deductible plans the payment will fall on patients.

Bean says:

Understanding what a physical is and what it covers is important in being a healthcare consumer in the United States. It is a broken system, but too many vote against fixing it.

However, consider this:
Person A presents for their physical and the doctor discusses blood pressure, depression screening, diet, exercise, immunizations, family history/risk profiles, labs, and any cancer screenings/prevention.
Person B presents for their physical and the doctor discusses blood pressure, depression screening, diet, exercise, immunizations, family history/risk profiles, labs, and any cancer screenings/prevention, but then also reviews questions about their knee pain, examines the knee, and provides recommendations for treatment of their knee pain.
Person C presents for just a visit for their knee pain and the doctor reviews questions about their knee pain, examines the knee, and provides recommendations for the management of their knee pain.

Did Person A and B receive the same services and did the doctor perform the same work? Or did they perform additional work for Person B? Is that additional work something that was more, less, or similar to the work performed for Person C? Is it fair to provide that work for the additional service to Person B for free, but to charge Person C for the same?

Health Insurance in the US is not a subscription to a medical care club where the subscription fee covers your activities throughout the year. It is a benefit program that pays for certain portions of the services you may seek out. When those services are preventative (i.e. no problem yet exists), they are covered fully. When they are not, they are covered in some part based on the agreement of your plan.

Whether or not you think that is right way to provide and administer healthcare is (or should be) the foundation for debate and discussion about the US healthcare system. Obviously it leaves a lot of people either avoiding care or feeling taken advantage of or bamboozled.

Karla Rioux says:

I went in for my annual free physical and my physician gave me a paper to fill out for advance directive. I didn’t ask for this, she just thought it would be a good idea. A month later I received a bill for an office call for advanced directive consultant.

Mary Porter says:

Over the past year this has happened to us. We are on medicare and private insurance. Somewhere tge policy changed and we were unaware. I am doyble billed copays and mysterious charges months later. I am told by the insurance co. And drs office it’s my fault for not undstanding the billing process!

Lou says:

This article summarize the current problem in America! I have family abroad, specifically in France, and they just can’t believe the medical system in the U.S. It just doesn’t make sense. Please excuse me if I sound too political but healthcare is a human right not be a business!

I got double billed recently and while I already called to dispute the charge with both the hospital and the insurance I have zero hope that the fee will be waived. What shocks me the most is that in my 12+ years in this country I had never had to pay for an office visit during a annual physical exam, unfortunately I relocated and had to find a new primary care provider.

My question to this doctor is, why would I be asked if I had any health concerns if that is not part of the physical exam? I am not asking for the amount I’ll be billed. I get it that’s not your department. However, if you are going to type somewhere that we went over an additional Q&A that took 5 additional minutes of your time which by the way I consider preventive (declaring a symptom could help prevent a bigger issue) you might as well let me know that you are billing my insurance for an office visit and that depending of my coverage it may or may not incur additional charges on my end. Wouldn’t be nice to leave it up to me if I want to proceed with our expensive conversation?

With all that said, I strongly believe that double billing is an unfair practice and a deliberate way for doctors to make extra profit at the patients’ expense.

Harry Charm says:

There must be more to this story. A physician cannot “double bill.” It’s illegal. It’s call “fraud.” Every medical visit and procedure has a code(s) that MUST BE recorded in a patient’s chart; no exceptions. The coding system (both ICD-10 and CPT codes) have become literally “oppressive” and are a significant factor in why so many doctors are “retiring” earlier than they planned. They want OUT of this crazy system! Doctors often spend more time documenting and coding patient charts than they spend WITH THE PATIENT! The doctors don’t like it, and neither do the patients. Also, the 3rd party reimbursement have become ridiculously low. Doctors must see 4 to 6 times as many patients in a given period of time, to make in the income they did 20 years ago! More patients per hour means less time with each patient – no getting around it. There are very specific rules that cannot be violated, one of which is that – with very unusual exceptions – a doctor cannot bill for two office visits on the same date (double billing). It simply cannot be done, and any doctor that does it is opening himself or herself to some BIG fines; even license revocation. Now, if different PROCEDURES and REASONS for those procedures are billed along with the appropriate code for the office visit – THAT can be done. That’s why I suspect we’re not getting the whole story here. The doctors are really not the bad guys. If you voted for Obama, congratulations, you got what you voted for. Always remember, YOUR decisions are consequences. To not understand this is called LEVEL ONE THINKING (look it up).

JJ says:

Most insurances you can actually be charged for an office visit during an annual yearly exam if you have complication that do not fall under the yearly exam guide lines. A preventive exam covers a review of immunizations, habits such as smoking and exercise, diet, and screening tests for colon cancer, breast cancer and diabetes, any other complaints now becomes an office visit.

Philip Althouse says:

Am a consumer attorney and former RN.. It’s very important to understand the extent of your insurance coverage plus deductibles and co-pays. Follow up with your insurer with questions about billing that seems improper. You might be right. Many states have consumer protection statutes that provide remedies for improper billing by healthcare providers.

jerry says:

I went in for my physical and was also double billed. After the appointment seemed to be comming to a close my Dr asked if there was anything else?? What was i supposed to think? I didnt know i was charged for a second appointment till my bill came and i owed 126$ for a dr visit. I called to get it straightened out and was told the bill stands. This is a terrible practice and i dont care if its the insurance company or the Dr’s offices fault, it shouldnt be at my expense.

B says:

Maybe I’m reading something incorrectly, but the phrasing of “The Affordable Care Act requires certain free preventative care for adults, women and children” seems to imply that adults != women.

JM says:

It sounds like the malpractice (abandonment) by your old PCP is one issue. It’s not okay for a physician to up-and-leave without notice.

I totally agree that it would be great for a doctor to let patients know the cost of their visit. Unfortunately, the doctor very likely does not know what your insurance will cover. It’s one of the big issues with the current insurance system… *what* is covered is between you and your insurance company, and the doctor just bills for the services provided. You weren’t “double-billed”, it was just a just a different itemized complaint (i.e., ‘well-visit’ is one part of the visit and ‘back pain’ is another).

Jasti says:

Omg! I went through this exact same thing throughout my pregnancy. I received $1000s of dollars in medical bills, even though my prenatal care was covered at 100%. Why? My doctor was billing me for asking certain questions, requesting certain medicines (that I had to pay 100% out of my pocket for–insurance would not cover), all because I was high-risk for the first trimester of my pregnancy!

It was incredibly stressful on me, and I incurred a mountain of medical debt. It’s not fair that they would do this to an expecting mother. I went back and forth between the doctor and the insurance. Now reading your enlightening post, I realize my doctor is to blame.

I will be referencing this post on my site in the future. Thank you so much for writing about a topic that many don’t discuss for whatever reason.