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%. 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%.

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.


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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