After a year abroad, my daughter came home last summer, unusually fatigued and with more severe asthma symptoms than when she left. After a thorough checkup, her new doctor, a family practice physician, referred us to five specialists, so I put aside a morning, and my insurance card, to make the appointments. Turns out, though, that to guarantee appointments with two of the practices, I also needed my credit card — to make a down payment on the visit.

Receptionists at those practices informed me that they would bill me upfront for a certain amount, which would be applied to any co-pay required at the time of my daughter’s visit. Any unused amount would be refunded. And if we didn’t show up for the appointment and didn’t give 24 hours’ warning, they would keep at least some of my down payment as a cancellation charge. One practice asked for $40, the other $90. And while I contemplated slamming the phone down in each case, in the end I relented to be sure that Dina, now 19, could see the doctors before heading off to her first year of college.

Consumers expect reservation agents to ask for a credit card to hold a hotel room or a table at a restaurant. But when a doctor asks for a hold fee, it feels jarring, perhaps because it turns what we think of as a healing encounter into a commercial one.

That’s exactly the point, says Kenneth Hertz, a principal at the Medical Group Management Association, a national trade association for medical practice managers. “No different than an airplane or hotel, if the appointment time comes and the patient isn’t there, that’s lost time — and revenue — forever,” Hertz says.

No one tracks the number of physician practices that require down payments, but calls to practices in the District and Maryland turned up 10 offices that either charge a hold fee in advance or require a credit card number that is billed if the patient doesn’t show up or cancels with little warning. An Internet search found scores of practices around the country, both primary-care doctors and specialists, that request a credit card number to hold an appointment.

At least 5 percent of scheduled medical appointments are missed, according to the Medical Group Management Association.

Many practice administrators say the hold fee reduces missed appointments. “It works beautifully,” says Jo Wodiska, the business manager for Reiter, Hill, Johnson & Nevin, an obstetrics practice with offices in the District, Falls Church and Chevy Chase. Wodiska says the practice she works for takes the card information but charges a $40 fee only if an appointment is missed. “Patients have the option of mailing in a check instead, which we cash only if they don’t show up or fail to cancel the appointment in time.”

Being charged after the fact for a missed appointment may be more common than being assessed a hold fee at the time of scheduling. Insurers won’t cover cancellation fees, and some plans prohibit doctors from charging their plan members with them. Call the member number on the back of your insurance card to check.

Even when patients show up, physicians can lose money. While insured patients typically remit their co-pay on the spot, physicians generally wait weeks to find out what insurers will or won’t cover for a patient visit; only after that will the doctor send bills to patients for the remainder — and hope to collect. They often don’t.

Unexpected fees

A 2007 survey by MTBC, a large medical billing firm in Somerset, N.J., found that 31 percent of its client firms in 30 states charged a missed-appointment fee, generally ranging from $25 to $100.

Hertz recommends that patients ask about cancellation policies when making the appointment. Some practices waive a fee if illness keeps you from turning up. The ethics policy of the American Medical Association supports cancellation fees as long as practices make their policies known. Medicare allows doctors to charge cancellation fees, so long as non-Medicare patients are also responsible for the same fees. Medicare, however, does not pay those fees and won’t reimburse beneficiaries.

Like airlines charging for suitcases, some medical practices have introduced other fees in the past few years for things that were previously free or for which a patient might not expect to pay. A physician’s office in New Mexico, for example, prominently says on its Web site that it charges a $10 fee to rewrite prescriptions for controlled substances, which expire seven days after first issued. A family practice physician in Connecticut charges his patients a per-visit malpractice insurance surcharge. Other surcharges reported among family physicians include a charge for referring patients to specialists and for a prescription or refill not attached to an office visit.

Goodwill goes a long way

Kimberly S. Cammarata, director of the Health Education Advocacy Unit in the Maryland attorney general’s office, recommends reading your doctor’s Web site carefully to see if things that were once free now come with a price.

And it’s worth checking with consumer protection officials in any state if you think a charge is unfair, says Cammarata.

Recently, I considered switching practices when I saw a sign in my OB-GYN’s office suggesting that patients reschedule appointments if they could not afford to pay the co-pay for that day’s visit. Then I remembered that my doctor at this practice had come to check on both my new babies in the wee hours of the morning after their birth, even though he hadn’t been the doctor on call.

Patients who give their credit card information to hold an appointment may want to use a card that’s not tied to a checking account, so that your money isn’t tied up at the doctor’s office until the appointment, said Travis Plunkett, the legislative director of the Consumer Federation of America. Plunkett also advises patients to stop by the practice’s billing counter — and check your statement once it reaches you — to ascertain what was actually charged.

If you can’t or don’t want to pay the booking fee, Hertz suggests asking to have the fee waived. Wodiska, the local obstetrics practice’s business manager, says that if a patient asks, her office will generally waive the fee. Goodwill by both patients and doctors may go a long way.

Several weeks ago, I made an 8 a.m. appointment for a mammogram at Washington Radiology Associates in the District. But when the morning arrived, I realized I had a school appointment with my son. I called the WRA office but didn’t find a message option; I sent an e-mail, offering to pay a cancellation fee. A week later I got an e-mail from WRA’s business office apologizing that no voice-mail option had been available, letting me know that no fee was needed and asking me to call back soon to reschedule the test.

Kritz is a health writer living in Silver Spring.