When Jill Wolfson called the psychiatrist last year for a prescription refill for her son, she had an unpleasant surprise. Up until then, the over-the-phone refill had been free. This time, she was charged by her doctor for the service, to the tune of $25.

"I was really astounded," says Wolfson, of Santa Cruz, whose son had long been seeing this psychiatrist for attention deficit disorder. "We go in for regular checkups to get his meds looked at, so it's not like we call in for refills without ever seeing him. It just seems like it should be part of the service when you're being charged $100 an hour." 
Ching, ching! Doctors — particularly primary care doctors — are increasingly billing for services that patients have long expected to get gratis: prescription refills, photocopies of medical records, phone consultations, family medical leave forms, medical disability forms, waivers of insurance premiums, waivers for handicapped plates.

Automotive forms. And life insurance premium forms.

Travel insurance forms.

And now, e-mail responses.

The practice, almost unheard of five years ago, has disgruntled some patients and is starting to come to the attention of consumer advocates, who denounce it as one more sign of a broken-down medical system.

"It shows that healthcare is like any other enterprise: It is revenue-driven," says Arthur Levin, director of the New York City-based Center for Medical Consumers. "The system is moving further and further away from being a public good to one in which the physicians are mere shopkeepers. How many times can they ring up the register?"

Even many physicians admit being uneasy about what they themselves refer to as "nickel-and-diming." And those who have so far bucked the trend suggest it is only a matter of time before they join the crowd.

"We think about it a lot," says Dr. Yul Ejnes, an internist in group practice in Cranston, R.I. So far, he says, "We've chosen not to do it, for the same reason we don't do a lot of things: We don't want to offend our patients."

But many doctors see the practice as a necessary evil in times of increased business costs, flat incomes and declining reimbursement from insurance companies — and the lack of a way to bill those companies for services that don't involve face-to-face patient visits.

"In the old days, we just did it, it was part of doing business and doctors would absorb the cost," says Dr. Richard Lander, a New Jersey pediatrician who currently charges $5 for school, camp or athletic participation forms. "But in today's climate with so much paperwork involved, doctors feel they can no longer give services for free."

Such "administrative surcharges" have been officially endorsed by several large medical organizations, including the American Medical Assn.

Lander recalls the reaction when he first started asking for the fee five years ago. "People were astonished. They were incensed. I had a few patients who left my practice," he says.

But whatever the initial sticker shock, it eventually wears off once patients realize they don't have a say in the matter. Schools increasingly require a doctor's release, and many sports activities won't allow participation without one. The consumer, in a nutshell, has no choice.



Patients pick up the tab

The trend goes far beyond filling out school forms. These days, some doctors refuse to write refills without seeing their patients in the office — because that way, it's a billable expense.

Although it is illegal, many doctors around the country now require their Medicare patients come in for an office visit if they want help filing an appeal in response to the new federal medication program, says Tatiana Fassieux, board chairwoman for California Health Advocates, a nonprofit association that tackles Medicare issues in California.

"What happens then is that Medicare gets charged for the office visit," Fassieux says. "And that's because physicians believe they are not getting sufficient reimbursement to do all the work they need to do to satisfy the Part D idiosyncrasies."

Other physicians, notably pediatricians, charge patients for after-hours calls, passing on the $15 or $20 per call that they're billed by the answering service.