Two West Hartford residents who were thrown out of one of largest medical practices in the state for complaining about its billing practice have won at least a minor victory by forcing the group to be more transparent about its charges.

Darlene Susco, the owner of a marketing firm, and Don Reder, a professional mediator and arbitrator, filed complaints last year with the state Attorney General's office accusing the Hartford Medical Group of double billing them for their annual physicals by charging both for the physical and for consultations during the physical.

Following a lengthy investigation by the Attorney General's office, the Hartford Medical Group has changed its policy and is now informing patients that they might be billed extra when they go for their physicals.

The Medical Group, with about 50,000 patients in the Hartford area, has insisted all along that it had the right to bill for additional charges if the physical included anything that was not included in its definition of what a physical. However, it did not warn patients about that policy prior to their visits, which had been established in the last two years.

Reder and Susco were told by the group that they were no longer welcome after they complained about extra charges from their physicals, which were not covered by their insurance carriers. Normally annual physicals are paid fully by health insurance companies.

While my internist and many other doctors consider a physical to be an all-inclusive session that would not result in extra charges even if new symptoms were discussed or prescriptions were simply renewed.

Other doctors and medical practices obviously want to make more money from the physicals and attempt to add on as many charges as they can.

They are able to tack on these extra fees because there are no set guidelines by the American Medical Association or any other medical body that specifies exactly what an annual physical should include. This permits doctors and medical practices to unilaterally decide what is included and what they can bill for extra.

"We discovered," said Attorney General spokeswoman Susan Kinsman, "that the threshold determination of when significant additional services are rendered is made largely on a case-by-case basis and … appears to permit services that may seem minor to a layperson, to be considered significant to a physician or billing agent."

"Mindful of this position and that the issue is just coming to the attention of consumers because (1) preventive exams are newly being encouraged through zero cost share benefits, and (2) many more consumers and employers are opting for high-deductible plans which have no cost share for the preventive exam, but high, initial out-of-pocket expense for regular office services, we determined that what was truly lacking from the consumer perspective was adequate notice of when these additional services are about to take place and patient options relative to those additional services. We thus worked with the Hartford Medical Group to address this primary issue, which was notifying patients when their physical examination crossed the threshold of a preventative wellness exam into 'significant additional services,' for which they may incur an expense, depending on their deductible under various medical plans," Kinsman said.

"The Group drafted, implemented and distributed a policy requiring its doctors to advise their patients when an examination was going beyond the scope of the preventative wellness exam, i.e. when a condition was discovered that required additional examination, tests or treatment significant enough to trigger the use of modifier 25. At that point, the patient is to be advised by the physician that he or she has determined that additional services are needed, but such services may cause the patient to incur a co-pay or cost share, or deductible expense, and further that the patient my opt to receive the additional services at a later time. A letter is also being sent to patients at the time they schedule annual physicals, explaining what the preventive or wellness exam entails and that the doctor will advise whether additional services may be required, which may trigger costs to the patient, depending on their deductible, co-pay, or coinsurance for non-preventive services."

Dr. Kent Stahl, medical director and chief executive officer of the medical group, said:

"The complaints last year helped to shed light for us all on a complex and confusing aspect of medical billing. But they gave us an opportunity to work to become a leader in transparency. We worked closely with the Attorney General to create clearer policies that we believe better serve our community and our patients."

My personal belief is that the more physicians are required to disclose about their fees and their conflicts of interest (like when they are paid by drug companies or they use medical devices they have a financial interest in), the more ability patients will have to make rational choices. They can choose to have a doctor who has their health as their primary concern, or they can choose a doctor whose primary concern is to make money.

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