Take two aspirin and pay our new annual fee in the morning. An increasing number of doctors are telling their patients something along those lines.

With health care economics what they are today, to get a clean bill of health, you may have to pay a second bill -- a fee that helps your doctor pay his bills. Sometimes called a "concierge fee," it's sort of like slipping a couple of Jacksons to the maitre d' to get a good table.

"I thought I read somewhere that this practice was illegal," complains Columbia reader David Blackman, after his wife's physician announced recently he was charging patients an extra $25 a year beyond the per-visit co-pay charge required by their medical insurance plan. "We have resisted paying [but] the office staff keeps insisting that we fork over the money."

The good news, Blackman says, is that his refusal to cough up the $25 hasn't affected the care provided. But he wonders what the bad news is.

The official take on these extra doctoring charges, so far, is that they are allowed and legal -- so long as they don't overlap Medicare and other medical insurance coverage or deny access to Medicare patients, says Michael Preston, executive director of the Maryland State Medical Society in Baltimore. "What physicians are seeking to cover with these charges are costs that they historically incurred that are not being covered by insurance payments."

The American Academy of Family Physicians' July-August 2004 issue of Family Practice Management journal clarifies which kinds of uncovered-service costs doctors hope to defray -- whether through nominal a la carte payments or an annual administrative, management or membership fee. The services include referrals, preauthorizations, filling out forms, phone and e-mail consultations, photocopying and no-shows. A few even mention a "malpractice surcharge."

Typically, the annual fees range from $15 to $75, but a report released in August by the Government Accountability Office found that 146 extra-fee physicians surveyed were charging fees ranging from $60 to $1,500. But the high end is bumped up by so-called "boutique medical practices" charging $1,500 to $1,999, or more, for premium benefits such as next-day appointments for non-urgent care, 24-hour telephone access and periodic preventive-care examinations. Preston calls boutique practices "the extreme version" of the more pedestrian fee-charging in most practices.

The GAO report concluded that fee-charging doctors did not prevent access for Medicare patients because the number of doctors doing this was "rising but small." But others are prodding the practice. The Maryland attorney general's office announced in July it is investigating the extra charges to make sure they don't run afoul of state laws prohibiting doctors from billing patients for the balance after HMO or insurance coverage.

For consumers, the fees seem like yet another nagging add-on charge, like the telephone company's incessant fee structure or the energy surcharges that taxis and hotels are passing down to the customer. Blackman says the policy statement from his wife's doctor says the $25 covers implementing "new privacy policies and . . . significant changes in office personnel and equipment." Other services, he says, are "subject to yet other surcharges."

Even the American Academy of Family Physicians' article, written for physicians, warns that the fees aren't without 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," it says. " . . . But physicians who charge for these services say that nearly all their patients have paid without question."

Preston says the increasing costs of doctoring and decreasing reimbursements from medical insurance are forcing some doctors to seek this kind of relief -- or go out of business. "The reason that we are starting to see this is that managed care is just squeezing physicians in a rising cost environment so they simply can't afford to perform services without charging," he says, adding that's especially the case for family practices and internists. "Physicians don't want to antagonize their patients, and they don't like pursuing these strategies, but there's no choice."

How many doctors are instituting these new fees? "We don't have any hard numbers," Preston says, describing it as the beginning of what may be a trend and adding that the Medical Society, which handles some patient complaints, hasn't received many about the fees. "Physicians are seriously interested in this and some have implemented it, but it appears it has been implemented in a fairly limited fashion. There hasn't been any real drumbeat about it from the public."

Junk Fax Solutions?

Last Sunday's column about the junk fax problem incited an onslaught of reader feedback mostly pleading for practical ways to stop the menace -- short of pulling the plug on the fax machine. If you've had any success using services, technology or your own resourcefulness in stopping illegal junk faxes, share the solution in an upcoming column. Contact information is below.

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