Not long ago, I blogged about a plastic surgeon who aggressively pursues patients who refuse to pay her bills. The state is suing her to make her stop and also considering lifting her medical license. The central theme is that she makes patients who she sees in the ED to sign a form stating that they will pay her. It is unlikely that the patients are aware of the amount of the fee up front. Then she won’t accept what insurance considers a reasonable reimbursement and goes after the patients with lawsuits and liens on their houses, ignoring the fact that balance billing of emergency department patients is illegal in her state.

A number of doctors have defended the surgeon. Many have said that the patient should have asked her what the fee would be. In my experience, that is a rare occurrence. I’ve been a surgeon for four decades and I can’t recall a single patient asking me what the fee for an elective operation would be. I hardly think a patient would ask at the time of an emergency.

Most patients either don’t think about it or don’t consider it an issue. In many cases, they don’t understand how the system works at all. Here’s an example.

A new patient arrived for an appointment with the doctor. At the time he called to schedule it, he was told that the doctor did not accept his insurance. At check in, the secretary reminded him of this, and having amnesia for the previous conversation, he was taken aback and said, “I thought everyone had to accept WeDontCare.”

Further questioning revealed he had a $5000 deductible policy and he had not used any of it yet this year. Even if the MD had participated in WeDontCare, the patient was shocked to learn that he would have had to pay for the office visit.

He was then told that the fee for the comprehensive new patient examination would be $250.00. When he balked at this, the nurse asked him why he chose such a high deductible policy if he didn’t want to pay for visits out of pocket. He said it was because the premium was so much lower.

The nurse explained that the point of a high deductible policy was that in exchange for the lower premium, he accepted the risk that some or all of the money saved might have to go toward paying for medical care, probably a reasonable risk for someone in good health. He didn’t seem to understand that unless he paid out of pocket for more than $5000 (less what the lower premium cost was) worth of medical care in a year, he was ahead of the game.

The patient then began to see the light. If this man, who was a retired financier, had never thought this through, how would anyone expect the average patient to do so?

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.