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. You may want to take a look at that post to get the details, but the central theme is that she makes her ED patients sign a form stating that they will pay her, although it is unlikely that the patients are aware of the amount of the fee upfront. 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 what her fee would be. In my experience, that is rare. 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 of the above in action: 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 $5,000 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. When he balked at this, the nurse asked him why he chose such a high deductible 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 $5,000 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 recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at and tweeting as @SkepticScalpel. His blog has had more than 325,000 page views, and he has over 4,000 followers on Twitter.