Explaining Second Visits

June 1, 2004

Occasionally, patients refuse to pay for a second office visit — or to pay a second copay — when the first visit did not reveal the diagnosis. How can we best handle patients who don't quite understand the disease process?

Question: Occasionally, patients refuse to pay for a second office visit - or to pay a second copay - when the first visit did not reveal the diagnosis. How can we best handle patients who don't quite understand the disease process?

Answer: More and more physicians will face such dilemmas given the increase of financial responsibility for patients.

In speaking to patients, I would focus first on the practical and ethical reasons for the additional visits so you don't sound like you are simply trying to generate another billable encounter.

Try saying something along these lines:

First, the human body is not like an appliance where all the parts are manufactured in standard sizes to specific tolerances and fit together in only one way to work properly. Not only is every patient unique, but everyone's body and how it reacts to infection, injury, or stress is also constantly changing. The lists of "what ifs" that physicians consider when someone becomes ill may fall into patterns, but there are no absolutes. That variability - from person to person and within each person - always introduces a small element of uncertainty, which is why medicine is considered both a science and an art.

Second, it is long established in medicine that since physicians cannot absolutely guarantee results, they should not appear to do so. And promising a free "re-visit" would be essentially telling patients that results are guaranteed when, in fact, the course of every illness or injury and what each patient will require is not entirely predictable. What's guaranteed is that the doctor is going to provide high quality care.

Finally, you can discuss with the patient the legal issues regarding waiving charges or copayments. Both Medicare and commercial payers tend to view "routine" waivers of copays as a misstatement of the physician's actual charge. A policy of always waiving the copay or deductible when a second diagnosis is required might be seen as a routine.