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From Family Practice Management

Should You Charge Your Patients for "Free" Services?

Posted 08/11/2004

Leigh Ann Backer


Stung by rising medical malpractice insurance rates and declining reimbursements that have them working more and earning less, family physicians are looking for new sources of revenue. Some have responded by finding niche services to offer their patients. Others are simply finding ways to earn more for the work they're already doing - by charging patients directly for services payers won't reimburse them for.

Completing forms, responding to patients' telephone calls, refilling their prescriptions and e-mailing with patients are just some of the services that family physicians are billing to patients - and getting paid for.

"My time and expertise are valuable, and if I don't value it, no one else will," says Anette Mnabhi, DO, a solo family physician in Montgomery, Ill., who has been charging patients for phone consults and various other services for more than a year.

Kathy Saradarian, MD, whose solo family practice is in Branchville, N.J., has a similar rationale for the fees she began billing patients for earlier this year. "I was staying hours after the office was closed, with staff, just responding to messages and requests. My medical opinion is my job; why was I giving it away for free? I just felt it was time that those patients creating the extra work and costs should start having to pay. No other professionals give it away for free involuntarily. And how many of my patients would stay late and work "off the books" for their boss?"

This approach is not without its risks. Billing patients for services they're not accustomed to paying for is sure to strain doctor-patient relationships that are already stressed by payer-imposed requirements. On the AAFP's practice management e-mail discussion list, where this is a frequent topic of conversation, family physicians worry that if they were to start charging patients for the extra services they provide, their patients might make life even more difficult than usual for their staff, or leave the practice, or complain to their health plans.

But physicians who charge for these services say that nearly all their patients have paid without question. For example, Alan Falkoff, MD, of Stamford, Conn., says 98 percent of his patients have accepted the policy he instituted in his four-provider practice in June 2003. Falkoff charges patients for a comprehensive list of services on an a la carte basis, as well as an annual administrative fee and a per-visit malpractice surcharge. (See "'Extra fee' models" for more information about each of these arrangements.)

Section 1 of 6

Leigh Ann Backer is managing editor of Family Practice Management.

Conflicts of interest: none reported.

Fam Pract Manag 11(7):43-47, 2004. ? 2004 American Academy of Family Physicians

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By the way, the article does address a timely topic here, charging for photocopies. This excerpt is taken from page 3 of the article:


State laws limit the amount that physicians can charge so contact your state AAFP chapter or medical society for guidelines. Some physicians charge patients from 25 cents to 75 cents per page, more for other requests from nonphysicians. Saradarian has provided this service for free for most of her 14 years in practice, but says she can no longer afford to absorb the cost. "With HMOs, patients change doctors practically every year. That's a lot of chart copying."

Edited by MightyMouse
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This clearly is a reflection of the health care crisis this country is in or headed for. I understand why doctors are doing this! Malpractice insurance is through the roof in many states. The cost of paperwork alone to process health insurance claims can be staggering.

If a doctor is good and treating me or my family professionally and helping solve medical problems, it's worth it to me pay them for these services. I think sadly a lot of people with our condition end up spending a lot of money (either our own or that of our insurance company) on inadequate care, unnecessary tests and office visits, etc.

That's why I think the most important thing we can all do is educate--or try to--the medical community and patients suffering from autonomic dysfunction conditions--as well as advocate for more research.

Thanks for sharing this.


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Katherine, I agree that this article is truly indicative of the state of medicine in the US.

Where I live, doctors have left in droves because the malpractice insurance is so expensive--especially in higher risk specialities like obstetrics, surgery, cardiology, etc.

My primary doctor left more than two years ago to start all over in a rural practice family practice--because, in his own words, he wanted to get back to being a doctor. He was exhausted from the time spent on the phone with insurers, dictating letters and filling out paperwork. Before he left, his practice implemented a 5$ charge per form (forms you bring in, such as disability paperwork), however the bulk of what he spent his time on was stuff he'd never get paid for. Also, reimbursement rates from insurers are ridiculously low (well, if your doc is awful, maybe they deserve to get little pay, but my doc was great)... for a more than 1/2 hour office visit, which would have cost me 75$ to 90$ if I paid out of pocket, my doc got a whopping 15 bucks.

I posted this article because it's written for a physician's publication--so you can see where they are coming from.

Nina <_<

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Boy, I must be really lucky, we don't have those charges yet. Of course, I live in South Dakota and we always seem to be a few years behind the trends. We aren't really a "rich" state to begin with so I guess that makes a difference. I have noticed it is very hard to get a dentist that excepts medicaid around here.

This article really makes since to me.


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It does make sense, and I can see where they are coming from- especially as Nina said, if you have a really good doctor who is making a mere $15 for an extended visit, then they need to make up for their time somehow.

However, the way our healthcare system is set up both the doctors AND patients are getting stepped all over...it's just not fair!

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I went into Alabama's AAFP and it did state that they could charge 1.00 per page, and I couldn't find where there was a limit in how much they could charge. I am still gonna see if I can find another way to get a copy of my medical records without paying a hundred dollars. Wish me luck.


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our largest hospital just laid off 180 nurses due to what they call "deadbeat" patients not paying their bills. funny, they built a 5 million dollar addition, paid for by of course, deadbeat patients. i can understand a doctor charging for a phone consultation, but not for a nurses call or a refill. i am a nurse and i couldn't look a patient in the eye and say, yea i'll call in the refill, that will be 25 dollars please. no way no how. i feel a large part of the outrageous malpractice prices have been brought on by the doctors themselves, (discounting ambulance chasing lawyers) they will not hold their own accountable. it is very much a good old boy mentality and peer groups will not hold bad doctors accountable and take their license to practice away from them. you have to trust me on this one. if doctors got rid of the trash doctors out there, the insurance would have to go down because there would be less suits. and frivilous suits have no business ever being started. i believe that insurance is outrageous, our own and malpractice. there really needs to be some laws put into effect for insurance companies and guidelines for sheister lawyers. and we need to weed out the bad doctors. i could tell you stories that would make your hair fall out, and these guys are NEVER punished with more than a little slap on the wrist. it's not so much the healthcare system as a whole, it's particular parts of it that need some major changes. morgan

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Morgan, I know stories that would make you sick too--my other half has worked on a trauma team, an open heart team, and also has been in charge of central sterile for more than one facility--No one seems to get punished for some pretty awful things I know have happened--and the good doctors have to pay the same malpractice fees as the bad ones. You know that old joke...what do they call a person who just barely passed med school? Doctor.


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