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As insurers try to limit costs, patients get hit with more separate fees

Leo Boudreau of Massachusetts was thrilled to find a psychologist in his insurance network to treat his teenage daughter for emotional stress related to a medical condition. The therapist worked out of a local hospital.

But he was surprised when the bill for each visit contained two charges: the approximately $100 he expected to see for the therapist – and a similar fee for the room, which was not covered.

“How could it be that the doctor was in network and the hospital was in network, but I had to pay separately for the room?” Boudreau said.

As insurers ratchet down payments to physicians and hospitals, these providers are pushing back with a host of new charges: Ophthalmologists are increasingly levying separate “refraction fees” to assess vision acuity. Orthopedic clinics impose fees to put an arm in a cast or provide a splint, in addition to the usual bill for the office visit. On maternity wards, new mothers pay for a lactation consultant. An emergency room charges an “activation fee” in addition to its facility charges. Psychologists who have agreed to an insurer’s negotiated rate for neuropsychological testing bill patients an additional $2,000 for an “administration charge.”

In some cases, such as refraction, the services were never typically covered by health insurance but had generally been performed gratis as part of an exam. In others, the fees are novel constructs. In any case, as insurers and providers fight over revenues in an era of cost control, patients often find themselves caught in the middle, nickel-and-dimed.

Some of the charges come directly out of patients’ wallets at the time of treatment and catch patients off guard. And if they do not write a check for the refraction fee, for example, many doctors will not dispense a prescription for the glasses.

Medicare requires doctors to inform its patients in advance about any service they are dispensing that they believe the government insurer will not cover, and provide an accurate estimate of what the patient will have to pay. But there are no such protections in commercial insurance.