Can they charge for that? Understanding the U.S. health system.
January 2, 2016 5:38 PM   Subscribe

Can a doctor perform a test without informing the patient that they will be charged? I'm new to the U.S. and have twice been slapped with bills for work that was done in the doctor's office, so I had no idea there would be a fee separate from the visit.

I went to the doctor 2 months ago and am now receiving a bill for a hydrogen breath test I don't even remember having. I believe that it happened, I guess - the date is correct, and the test is used for the symptoms I had, but I definitely had no idea at the time that I or my health insurance would be billed for this. My insurance covers part of the bill, but I still have a deductible. Is a doctor's office allowed to perform in house testing without informing the patient that they will be charged? Had this been outside lab work I would have realized (and remembered).
posted by Miss Viola Swamp to Health & Fitness (11 answers total) 3 users marked this as a favorite
The short answer is yes.

The longer answer is that insurance coverage is not standardized in the US, and outside of a few well-defined areas, the way things are covered varies wildly from policy to policy. Your doctor almost certainly doesn't know whether the testing will result in out of pocket cost to you. They know they will bill for it, but there's no way for them to know in that moment in the office whether it will hit your personal deductible, be covered as part of the copay for the visit, have a separate copay, or something else.

The even longer answer is that physicians bill using a set of codes (called CPT codes). There are a set of codes for what we would consider an "office visit" - which consists of talking to the doctor, getting vital signs, and physical examination. Tests have their own codes that can be billed in addition to that office visit code. This isn't meant to be deceptive to patients, and it is an important part of the economics of running a medical practice. If anything is happening in the visit other than talking to the doctor, getting vital signs, and having a physical exam, then it is reasonable to ask if it will be billed separately. I guess the question is what you would do with that information - refuse the test? That may mean that the physician feels like she can't diagnose or treat.
posted by jeoc at 5:49 PM on January 2, 2016 [7 favorites]

Yes, the short answer is yes, and the slightly less-short answer is that doctors don't know what a particular insurer will regard as a separate charge for a particular plan, and to some degree don't care. (I've seen separate charges for downloading medical device data -- i.e. plugging in a USB cable -- that insurers won't cover as part of the visit copay. I've seen tests that the staff repeatedly insisted were covered by the standard specialist copay be billed at the much higher outpatient hospital rate because the local hospital took over the specialist.)

It's up to you to second-guess as best you can, and to develop a willingness to say "is this going to be billed separately?" for anything beyond the rudiments of an office visit. If you're certain that a particular test was not administered at the time, and you feel like the doctor is padding the coding items with something that might be used but wasn't in your case, then you need to follow up with the doctor's office and possibly your insurer. This is not conducive to a great relationship with your doctor, and may mean you have to find different doctors who are more willing to disclose anything that's going to earn its own billing line item, but, y'know, yay America greatest healthcare in the world or something.
posted by holgate at 6:03 PM on January 2, 2016

Seconding everything jeoc said. I went to the doctor for what I suspected to be a UTI. I got 4 bills, one for talking to the doctor, one for the lab who processed the blood test, one from the lab who processed the urine test, and one from the (different) doctor who looked at the results. It sucks and there is basically nothing you can do.
posted by desjardins at 6:03 PM on January 2, 2016 [6 favorites]

Just to add, the large wodge of paperwork that you have to sign before you even get past reception will include some standard rubric saying that you consent to and take financial responsibility for every jot and tittle of your treatment. It sucks and there is basically nothing you can do.
posted by holgate at 6:11 PM on January 2, 2016 [1 favorite]

At this point, my advice for people new to the US health system is this: assume that you'll be billed for literally everything--your initial copay (or the up-front fee, if you don't have insurance) buys you the right to exchange words with a medical professional and not much else. Any test or treatment that's offered to you will almost certainly come at some additional cost, even if it's not presented as such.

Also, if you're starting your question with 'can they really--' the answer is almost always yes.
posted by MeghanC at 6:12 PM on January 2, 2016 [6 favorites]

What state are you in? Some (like NY) have "surprise bill laws", although I don't know if that would apply in that situation.
posted by ThePinkSuperhero at 6:31 PM on January 2, 2016 [1 favorite]

MeghanC has it right. Yes, they can probably do whatever shady, shitty thing they did, and no, they do not have your best interests in mind ever. Assume you will be charged for every damn thing.

Large medical practices (especially in specialties where insurance is very likely to nope out entirely, like fertility treatments) sometimes have someone on staff whose entire job it is to know about insurance and know about how the doctor is going to bill your visit/procedure(s) and may be able to give you some ballpark ranges. This is really just in cases where you're going to need something major and expensive done, this is not a conversation that's possible at every office visit, or at every office.

And keep in mind that an insurance company's worst enemy is an informed consumer. They don't want you to know what they do and don't cover. It's bonkers. We're constantly told how great our system is because it's the FREE MARKET!! but... it's absolutely not a free market in any way, shape or form. It's like going to a supermarket where nothing has a price tag and you can't return anything if you find out you actually can't afford it when they ring you up.
posted by soren_lorensen at 6:32 PM on January 2, 2016 [17 favorites]

It seems to me that it would be worth your time to contact your doctor's office and ask about this. The test involves fasting for 12 hours beforehand, and blowing into a balloon. I would think you would remember this. If you don't, I wonder if maybe somehow you were billed for this test because the doctor meant to administer it, but for some reason the test was not in fact administered. If that's the case, you should not have to pay.

If you are told that the test was administered, ask for a copy of the written results to confirm that.
posted by merejane at 10:32 PM on January 2, 2016 [10 favorites]

People do get billed for tests they did not actually have. I know someone who has been battling a hospital for years over an ultrasound that did not occur (the hospital has no results for it). She is able to do that because she owns her house, pays cash for everything, and doesn't care if they try to ruin her credit. When I had an eye exam, the office visit and the exam itself were billed as separate items, so my co-pay did not cover the exam. I tried to dispute it, but it was hopeless. The system is insane. If you don't believe you had the test, you can at least try to dispute it.

Most doctor's offices will have you sign a form that says they can't guarantee that anything is covered by insurance and you agree to pay for whatever isn't. It is virtually impossible to find out in advance what anything is going to cost. The system is totally rigged against the consumer. I'm sorry you are having to deal with it.
posted by FencingGal at 5:42 AM on January 3, 2016

I'm 52 and this is a relatively new thing in doctor billing in the US, like 10 years ago you just got one bill and now you get all these separate bills for one visit.

My insurance covers part of the bill, but I still have a deductible.

One thing to beware of which I have learned the really hard way and I'm still battling my insurer over this: sometimes your doctor's office will send you to a place that IS NOT IN NETWORK and your insurance won't cover ANY OF IT because there's no deductible for out of network services, period. Check the fine print of your policy. I have what I thought was a decent plan and in the teeny tiny fine print, even though it says right on the card $2000 deductible for out of network services, it turns out they won't cover ANY out of network service, period.

No lie: my son was at Children's Hospital in Boston and they sent him to get an MRI done at a place on our way home because they were backed up and it was faster to get it done on the way home. $2400 and they won't cover a penny of it, but if we had stayed and waited 9 hours to get it done at the lab at the hospital, it would have been covered.
posted by yes I said yes I will Yes at 5:58 AM on January 3, 2016 [1 favorite]

One thing to beware of which I have learned the really hard way and I'm still battling my insurer over this: sometimes your doctor's office will send you to a place that IS NOT IN NETWORK and your insurance won't cover ANY OF IT

I got seen at an ER a couple years ago for a head injury. The hospital was in-network. The ER was in-network. The CT tech was in-network. The ER doctor was not in-network. I got a bill for $500 for talking to the doctor at the ER. Fortunately, I live in one of the states (PA) where this is actually not legal. If you go to an in-network ER in Pennsylvania, your insurance must pay in-network rates even if one of the health care practitioners you saw was out-of-network. It only counts for ER visits because if you're there you're probably under duress and can't make a choice to go somewhere else or see someone else, so if you're being admitted to a hospital for any other reason, you still need to quiz EVERYONE about whether or not they personally are in your insurance network (regardless of whether the hospital is). And in states without the law that PA does, you also have to do that for ER visits. So in my case I sent a letter to my insurance company quoting the applicable law and they paid up fairly quickly. Yet another reason why a well-informed consumer is an insurer's worst customer.

Like I say: bonkers.
posted by soren_lorensen at 11:45 AM on January 3, 2016

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