Cost of Physical Exams

December 28, 2014 3:05 PM

I recently went for a general physical exam with a new doctor and got back a $900 bill. Is this normal? What can I do? Are there consumer rights I should be aware of?

I'm in my 20s and rather new to this whole medical experience. I went to my first physical exam in years to a new doctor and got back a bill of ~$900. The exam included general questions, checkups, and some blood tests. The costs broke down to:

~$400 New Patient (?) - "PREV VISIT, NEW, AGE 18-39"
~$200 Office Visit
~$300 Blood Tests

I have medical insurance, but it turns out I have to meet a high deductible before they would pay anything.

I was expecting and planning for a $200 bill for an office visit and therefore can somewhat understand the $500 total for the office visit and blood tests. But I was not expecting the $400 charge for being a new patient (or am I misreading it and it's something else?)... Is this normal? It seems odd to me that it would cost almost as much as the visit and blood tests combined...

What are my best options to deal with this exorbitant cost? I plan to call both the insurance company and doctor's office on Monday to see what can be done. Any advice on how I should approach my case with them? Should they have told me about the costs in advance? Any consumer rights I should be aware of to best advance my case?

Thanks in advance for any help you can provide!

posted by pockimidget to Health & Fitness (20 answers total)

Is that a bill-bill, with an "Amount Due" line, or an "Explanation of Benefits" with a "Patient Responsibility" column?
posted by KathrynT at 3:11 PM on December 28, 2014 [1 favorite]

Call your insurance company and make sure the claim has been processed- even if your insurance doesn't pay, you should get a discount for using an in-network physician (assuming you did). If the claim has been processed, get a copy of the EOB from your insurance company that tells you how much you owe the doctor and lab. I don't think $600 is a totally outrageous charge for a new patient visit, although it might be higher than others charge. You can also ask the doctors office what they billed out to the insurance company; if they give you the CPT codes used, they should be able to explain what they mean or you could google them. That should clear up the $400/$200 mystery.
posted by ThePinkSuperhero at 3:14 PM on December 28, 2014 [3 favorites]

Best answer: Wow. $900 for a physical. $400 for a new patient fee that you only find out about after the fact is completely outrageous to me.

That said, you may have more options than you think. With Obamacare some coverage of things like health checkup visits every few years is mandated, even with high deductible plans. We have high deductible insurance and made essentially the same mistake as you (though not as expensive) before finding that out.

If this was me, I'd be looking hard at not paying at all. I might talk to a lawyer. Obviously a lawsuit doesn't make sense here, but maybe buying a half hour of advice from a lawyer might be worth it. Last I knew, in my state, medical bills had extra consumer protections, in particular your credit could not be dinged for late payment. I'd look into this.

I would not contact the docs office at all unless I decided to pay, and wanted to go the route of asking for a discount.
posted by mattu at 3:19 PM on December 28, 2014 [2 favorites]

How long was your appointment? Usually a regular office visit will be maybe 10-15 mins, but an appointment for a new patient is longer, 30-45 minutes, and you pay extra for that.

Definitely call your doctor's office and they ought to be able to help you. If you have a high deductible plan I would recommend establishing an HSA and planning to deposit the amount of the deductible in it annually, if that's feasible for you. This will be beneficial to you tax-wise because you won't be paying taxes on the amount you spend on medical costs (it basically gives you like a 20% boost on your money, depending on your tax bracket)

Also, it would have benefited you to have this appointment in 2015, because if that's your only medical expense on the insurance in 2014 you're definitely not going to meet the deductible this year, whereas it would have helped you meet it for 2015 if you needed more done. With the HD plans you have to strategize somewhat to make them most financially helpful for you.
posted by treehorn+bunny at 3:19 PM on December 28, 2014 [1 favorite]

I got a bill from the gyn and LabCorp some weeks ago that my insurance company mistakenly declined until I called them. Then they apologized and took care of it.
posted by discopolo at 3:20 PM on December 28, 2014 [2 favorites]

Response by poster: To clarify, the bills (including the EOB) are from both the insurance and doctor. They both say the same thing--that I owe that much. So the insurance did run over the bill already and expect me to pay that much (they only paid about $10 for me using an in-network doctor). I looked up the CPT code of 99385 and didn't find much without paying, but it seems to suggest a preventative exam for a new patient. And the exam probably took about 30 minutes before the blood tests. I can't quite remember the exact duration, so perhaps that was the factor.
posted by pockimidget at 3:27 PM on December 28, 2014

New patient fees are now a thing, unfortunately. Call billing in Monday or after the new year, explain you can't afford the bill and see what they can do to reduce or waive it. Or, maybe take the route that you didn't agree to it (but who knows what you signed.) It depends on the situation and what you're comfortable with.

Supposedly they are illegal in a few arrangements/locations but I don't know for sure or the details. You'd have to ask a lawyer.
posted by michaelh at 3:31 PM on December 28, 2014 [1 favorite]

Assuming this doctor is in-network for the insurance company you're using, find out what the insurance company usually reimburses for those services and ask to be charged at that rate.

"New patient fees" are becoming more common and are now an accepted charge, but you should find out what your insurance company's standard for that service is and pay that, not the made-up price that the doctor is charging.

We are not yet at the point where the same legal regime that obligates mechanics to disclose their estimated fees before performing services has caught up to cover doctors.
posted by deanc at 3:37 PM on December 28, 2014 [2 favorites]

Best answer: The best way to utilize a High Deductible Health Plan (HDHP) is by setting aside roughly the annual deductible into a Health Savings Plan. If you use it all, insurance covers the rest. Any unused money carries over to the following year, and at retirement age can be withdrawn without penalty.

HDHPs trade copays for lower premiums. My annual premiums for health insurance are around 12k for just myself on a normal plan. When I had a high deductible option available, my employer offered to contribute about a thousand of the premium difference into a HSA for me.

But you're on the hook for doctor bills minus whatever discount your insurer may have negotiated. Theoretically, this makes you motivated to ask doctor's offices questions about prices up front, but they have very little incentive to discuss it with you. And yes, doctors are expensive, thats why they retire very rich people as a class, even though they take on six figure student loans.

Your best option to cover future exorbitant costs is to set aside a full year's deductible into an HSA, or find a different sort of insurance plan.
posted by pwnguin at 3:55 PM on December 28, 2014 [2 favorites]

One of the deals with ACA is that you get one annual, full physical as part of your insurance. If you're a woman, you get a free well woman exam, and if you're over 50, you get mammograms and colonoscopies. A chem 7, and other standard tests are typically included.

So you may owe some of that, but not all of it.

Also, with a HDHP, typically you contribute a bit into an HSA (Health Savings Account) with a debit card. You elect to put certain amounts of money on the card, but your employer typically contributes around $500.

Also, if your doctor is in-network, that means he/she has agreed to charge the going rates, "reasonable and customary" charges.

Having health insurance is a great first step, but you do need to make a good effort to understand it. Also, all providers are required to tell you what the charges are before charging you. So always ask when making your appointments. You'll get push-back, because with 1000 different plans, it's a real PITA for the office to tell you, but you should be able to get at least ball-park information.

This isn't over, do a bit of sleuthing. Get your paperwork out, ask HR if there's an HSA somewhere.
posted by Ruthless Bunny at 3:55 PM on December 28, 2014 [8 favorites]

Our insurance pays about $10 for the basic annual exam blood work. You should be getting the negotiated rates, even if its all out of pocket due to the deductible.
posted by COD at 3:58 PM on December 28, 2014 [2 favorites]

Best answer: So the new patient part with the age? That's a wellness exam. They charged you for a well adult visit, plus an office exam. Which they can do, IF you had chronic diseases that you discussed or were treated for an acute illness -- that would justify the $200 on top of the $400. If it were me, I'd ask my insurance company to request the medical records for the visit and audit whether that was an appropriate charge.

FWIW, I do billing/coding for several doctors my family practice docs charge closer to $200 for well patient visit, but that can vary widely depending on your location.
posted by kattyann at 4:55 PM on December 28, 2014 [3 favorites]

If you do have access to a HSA, then you can make delayed contributions for 2014 until April 2015, which would be worth doing to at least get the small tax break.
posted by the agents of KAOS at 5:04 PM on December 28, 2014

Best answer: While those referencing ACA are correct about not being charged for wellness annual exams, currently the ACA provisions do not apply to a lot of existing group plans - that isn't required until 1/1/2018. So if it's a new "Obamacare" insurance plan you have, I think you have a solid argument, but if it is an existing health plan that is not yet required to abide by the "free preventative care" rules you may have to argue that the bill is too high on different grounds.
posted by cecic at 5:18 PM on December 28, 2014 [1 favorite]

Worse case scenario, if you find out this is the amount you owe, most doctors will work out a payment plan.
posted by tamitang at 5:57 PM on December 28, 2014

One thing I learned, the hard way, is to ask what the estimated charges are going to be. You can also ask for an exact cost. I no longer wait to find out what my share of cost is going to be because even 20 percent of something can be very pricey.
posted by cairnoflore at 6:13 PM on December 28, 2014 [1 favorite]

Mod note: One comment deleted. Just a reminder: as infuriating as the subject of healthcare costs can be, we do need to stick to specifically answering the question rather than generally commenting about the topic. Thanks.
posted by taz (staff) at 2:13 AM on December 29, 2014 [1 favorite]

You do unfortunately need to plan to devote a chunk of your schedule to this, and I'd suggest going in person if you are able.

I recommend you do not show up in person to discuss billing matters without an appointment. Many offices outsource billing; the people you need to talk to might not be in the same physical location as the doctor.
posted by ThePinkSuperhero at 7:37 AM on December 29, 2014

First, I'd double-check with your insurance that you don't get a free wellness visit each year.

Definitely call the billing department, explain your situation, and ask if they can reduce the bill to the amount that they'd get if insurance was paying. For some ridiculous reason doctors have a super-high "list price" but a different "negotiated" price with each insurer that is *far* lower. Like 50%.

After that, ask for a payment plan over x months.
posted by radioamy at 9:11 AM on December 29, 2014

Best answer: Office visits are reported using the CPT section titled "Evaluation and Management". Within the Medical Coding world, they're often referred to the short hand "E&M".

99385 is indeed the E&M code to report a preventative exam for a patient who has not been seen by that provider or another provider within that office in the last 3 years and it is based on age of the patient, not time spent. If you had the doctor evaluate additional issues that went above and beyond the preventative exam, they can charge a different E&M for those services and that may explain the "Office Visit" charge, but without a CPT code, it's impossible to verify.

Getting it paid for is another battle, and that really depends on the specifics of your insurance plan. Whether the insurance company pays for it could depend on which ICD-9-CM diagnosis codes the office reported. Although, with your high deductible it may not matter and unfortunately those are generally based on calendar years so your expense won't help you if you have any other medical bills next week.
posted by Apoch at 1:31 PM on December 29, 2014 [1 favorite]