Both the science and the practice of medicine have changed dramatically over the past several decades. New procedures, medications and treatment options have vastly improved the medical profession’s ability to diagnose and cure disease, repair damage due to accident or injury, and test for various ailments and conditions whose early detection and management helps save lives.
The business of medicine has changed considerably, as well. Years ago, a person visiting his or her doctor would pay for the services provided without the intervention of an insurance company acting as a middle man or co-payer. Financial arrangements were between doctor and patient, and payments were negotiated privately and with a certain amount of flexibility.
Today, with approximately 87 percent of all Americans covered by some form of health insurance, that private, fee-for-service model has largely been replaced by insurance plans that share costs with their beneficiaries based upon various coverage formulas, and negotiated price agreements made with physicians for services they provide.
This new business model makes it difficult to know what any individual doctor visit might cost. Not only does it depend upon the extent and complexity of the medical service(s) rendered, and the amount of time spent in the delivery of those services, but also on the way in which the doctor is paid — both by the patient and by his or her insurance provider (and by whether that provider is a private company or a government entity like Medicare or Medicaid).
In addition, most private insurance plans have in-network providers whose fees differ from those of their out-of-network colleagues, as well as from one another. All of these factors help to complicate the ability of a patient to assess doctor visits costs.
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Average Doctor Visit Costs
There are several ways in which consumers of health care services can get reasonable estimates of what a visit to their primary care doctor, or a specialist’s office, might cost. This is important information to have in hand, since the costs are typically less than the fees at an urgent care center or an emergency room.
The American Medical Association publishes a web-based reference formulary of physician charges, known as CPT codes, for many preventive services and office procedures. The information on these payment charts is broken down into several categories, including the average charge for a particular procedure as submitted by a doctor’s office.
For example, in 2011 in America, the average charge for an office visit for an established patient, level 3, requiring approximately 15 minutes with a doctor, was $104. The average total paid was $69. Some more examples: a flu vaccine incurred an average charge of $25; a cholesterol test has an average submitted charge of $72; and a glucose tolerant test (GTT) has a submitted charge of $60.
Another useful cost estimator, particularly for those who are privately insured, is the Healthcare Blue Book, an online guide to health care pricing, with amounts based on the typical fees physicians nationwide accept as payment from insurance companies.
Here are some Blue Book prices for doctor office visits:
- Office Visit, New Patient, Level 1 – Very minor problem requiring counseling and treatment, may require coordination of care with other providers – approximately 10 minutes with doctor – $68.
- Office Visit, Established Patient, Level 5 – Complex medical problem(s) requiring comprehensive evaluation- approximately 40 minutes with the doctor – $234.
- Tetanus shot – $28.
- Eye Examination, New Patient – $234.
Private Insurance Deductibles, Co-Pays and Co-Insurance
Almost all private insurance policies require the insured person to pay a co-pay when visiting a doctor or any other health care provider. The co-payment amount varies depending on the insurance plan. Typical co-pays for a visit to a primary care physician range from $15 to $25. Co-pays for a specialist will generally be between $30 and $50.
Most plans also require that the insured pay a deductible before the insurance provider will take over payments to a physician. Deductibles vary widely among plans, and some benefits may be available even before the deductible is met. Also, co-pays may or may not be included in meeting the deductible.
Co-insurance charges are usually stipulated as a percentage of the total bill. For example, an 80/20 policy is one in which the insured pays 20 percent of the bill and the insurance company pays 80 percent, but only after the insured has paid a co-pay and met the required deductible.
When a doctor orders tests from a diagnostic facility, they may be paid for by insurance, depending upon the specific test and the policy in force. If a particular policy does not cover lab tests, the bill must be paid by the patient.
Doctor Visit Charges Are Not Set in Stone
It is important to remember that, even today, doctor visit fees are often negotiable, both before and even after an office visit. Discounts are widely available for self-payers, and like any other consumer product or service, individuals can shop around to locate the best price for a particular procedure – especially if they know in advance what the average charge is for a particular service, or what other providers in the area are asking.
Also, some physicians have decided to opt out of the current insurance payment model and have returned to a less administratively complex, fee-for-service approach. Others have elected to do away entirely with fees, charging their patients one annual price for any and all services rendered during the year.
Patients who are having trouble paying their medical bills, including doctor visits, may benefit from talking to a professional debt relief company experienced in negotiating payments on their behalf. Either debt settlement or debt consolidation may be an appropriate option to help settle overdue or unmanageable accounts.
Patients who qualify for Medicaid, which is the federal/state insurance program for low-income individuals and families, can have their doctor visits covered. Eligibility requirements vary from state to state.
Savvy consumers will benefit from communicating with their insurance companies as well as with their own health care providers so that they have the best available estimate of what their doctor visits will cost them, and whether or not they are getting the best value for their money.