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Medical Bill Sticker Shock, Part 2: "Piling On"



This is the second in the series of articles attempting to help you understand how charges for a simple visit to the doctor can be so expensive.  Last time I explained how prices for services are inflated, especially for those without insurance ( read Part 1 here:  http://tinyurl.com/ycbscr5x ).  This time, I will explain how charges can add up in unexpected ways, exploiting the billing system by using a method I call:


“Piling On”


When you go to the doctor or another medical facility (lab, x-ray center, etc), you expect one charge for one service, right?  Maybe you have several distinct things done (exam, vaccine, x-ray, etc.), but the final bill should simply be a sum of those services, right?  Same as when you go to a restaurant, you will pay for each item you order, but the prices are clearly shown and nothing should be added that you don’t recognize.  But what if the restaurant added a “dish washing fee” to your bill?  Or maybe a “server attention” charge, or "use of our air" fee?  You would not be happy about that, would you?   Of course not.


Well, Big Medicine will do the same kind of thing to you when you are seen or have tests done.  


For example, take a routine well child visit:  A healthy 17-year-old young lady needed a check-up for routine purposes and for a college scholarship application, along with a meningitis vaccine booster.  Seems simple: two charges total, right?  Wrong.  In addition to the doctor exam fee (preventive visit code), the practice also billed for a vision screen, a hearing screen, and developmental (early language/milestone) screening, which was just a form with a list of questions that was not even mentioned later.  This is the summary of the visit charges:



So, a simple well-child visit for a healthy teenager and one vaccine resulted in over $500 in charges!  See how "piling on" works?   By the way, this example is not made up.  The patient was our oldest child, and this is the exact bill we received for her checkup at a local Big Medicine practice (we don't have much choice, either).


Is this fraud?  No.  Each of these separate services is technically allowed by "the system," but doing so in this case is exploiting that system - following the letter, not the spirit of the rules.  The separate charges for the hearing AND vision screens are intended to be used when those tests are done by themselves, not as part of an overall physical.   The developmental screen?  That is really pushing it.  Big Medicine practices will just have the parent (or the patient themselves in this case) fill out these short questionnaires without informing them there are charges for it.    You may have seen this when you have taken your own child, possibly even received a bill for it when insurance refused to pay.


You know all those signatures required every time you go, and that you cannot actually see what your are signing on the computer?  One of those is consent to be billed for some things that insurance will not pay for.


And just because insurance may pay for these does not make it “OK”, it increases costs for everyone.


For comparison, in our practice we believe the vision screen (reading the letter chart) and hearing screen are important tests, but we consider them just a part of a thorough well-child exam and do not charge a separate fee to do them.  Developmental screening questionnaires can be useful, in the right setting, but only if they are actually addressed and not just used to check a box for additional charges.  


We don’t make anything on vaccines (or lab tests), they are already too expensive, and we do not charge $40 to just give a shot,either.  That is just silly.


Lastly there is the infamous “Facility Fee” which I have written about before (my letter to the editor in the Winston-Salem Journal here:   http://tinyurl.com/ybfkg6p2).  In short, this is purely a tacked-on extra $50-100 (or more) that Big Medicine clinics are allowed to add on top of the all the other inflated and excessive charges just because they are a hospital system.  One local Big Medicine system attempts to explain this, hilariously, on its website: “When you see a physician or receive services in a hospital-based outpatient clinic, you are being treated within the hospital rather than the physician’s office.”   Right....


You get the same doctor, the same staff, in the same clinic providing EXACTLY THE SAME SERVICE but suddenly you are now magically "in the hospital", not a clinic.  And with a big additional fee .  I am not making this up, read my letter for more details…


In summary, big practices and systems are likely to nickle-and-dime services and exploit loopholes to “pile on” the charges whenever you are seen,  but hopefully you now can better understand this sleazy practice pushed by greedy non-medical corporate raiders using medical care to get rich.   I don't accept this as the way it has to be, and neither should you.


Next time, we will get to know the gimmick I call: “Upcoding"


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