By Michelle Crouch
Co-published with The Charlotte Ledger
When Mominul Mahim’s daughter needed a refill of her eczema medication, the Huntersville dad made the request through Novant Health’s MyChart app, which connects him to his daughter’s medical record and to the clinic.
He assumed the process would be cost-free and easy, since the app has a notice that says refill requests between visits are free.
Weeks later, Mahim was shocked when he received a bill for $41. The health care system told him his email exchange with the doctor qualified as a telehealth visit that took six minutes of the physician’s time.
Mahim, 31, said he disputed the charge for more than a month before giving up and switching his children to another practice in frustration.
“They acknowledged the disclaimer was there but still did nothing to help me,” he said. “It feels like they’re more interested in protecting their bottom line than providing quality, honest care.”
A spokeswoman for Novant Health did not respond to specific questions about Mahin’s bill but sent the following statement:
Our goal is to provide patients with access, convenience and top-quality care, regardless of the setting. As telemedicine has grown significantly in recent years, standards have been established to account for online medical consultations. Services patients may be billed for include e-visits, diagnostics, consultations about new health concerns, and non-standard requests.
More hospitals charging for messages
The case highlights a broader ongoing debate about the email fees, which have become common since the federal Centers for Medicare & Medicaid Services created new billing codes that allowed providers to charge for messaging with patients.
Other large health systems nationwide that now charge the fees include the Cleveland Clinic, Houston Methodist, Northwestern Medicine, the Ohio State University and the University of California San Francisco.
Advocates say the fees are needed to fairly compensate physicians for the time they spend messaging with patients — an online workload that has ballooned about 50 percent since the COVID-19 pandemic.
Critics, however, worry that the fees could discourage patients from communicating with their health care providers. They also fear that the fees could be exploited by health care systems as a new revenue source.
Billing permitted for emails that require medical decision making
Novant began charging for physician-patient message exchanges in 2022. The health care system told the Ledger/North Carolina Health News in 2023 that it had billed for less than 1 percent of all MyChart messages its providers received, and that the average charge was $10.
A notice to patients in the Novant MyChart app gives patients a heads-up that they may be billed if they bring up a new issue or ask for medical advice. The note also says:
MyChart messaging allows you to connect with your provider between visits for things like lab results, prescription refills requests, or for follow-up visit questions. These are considered routine requests and are provided free of charge.
Under federal rules, a doctor must spend at least five minutes on correspondence with a patient within a seven-day period in order to bill for it, according to A Jay Holmgren, an assistant professor in the department of medicine at University of California San Francisco who has researched the fees.
The correspondence also must require medical decision-making, Holmgren said.
“In general, a straight prescription refill request should not generate a message fee,” he said. “If you have a back-and-forth exchange about it or ask about side effects or for the doctor to consider alternatives, that’s something you might be billed for.”
A four-sentence reply sent in three minutes
Mahim’s 1-year-old daughter was diagnosed with eczema in August during her one-year checkup at Novant Health Pediatrics Berewick. The doctor prescribed a topical oil to manage her eczema.
The supply ran out, Mahim said, so on Oct. 22 he requested an automated refill through MyChart — as he’s done with other prescriptions in the past.
The refill request was initially rejected, Mahim said, so he sent a quick message to his daughter’s pediatrician, Amra Zuzo, asking if it could be refilled.
Dr. Zuzo responded quickly — just three minutes later, according to a screenshot Mahim shared of the exchange.
Zuzo’s four-sentence response said, “Hi, yes, I denied it because we haven’t talked in a while. Thank you. I’ve sent it in. Please let me know if it isn’t helping or if you’re having to use it longer than 2 weeks at a time.”
An unsuccessful appeal
After he got the bill, a representative at Novant’s billing department told Mahim the only way to reverse the charge was to get the doctor to change the billing code, he said.
But when Mahim talked to the clinic administrator, Olivia Vaughan, she refused to reverse the charge. He said she told him the charge was legitimate because Zuzo spent six minutes messaging with Mahim about the refill, qualifying it as a legitimate telemedicine visit.
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According to Mahim, Vaughan also told him that she spoke with management, and they were going to work with the marketing team to change or remove the disclaimer about refills from the MyChart app.
The Ledger/NC Health News emailed Vaughan, but she did not respond.
Novant did not respond to a question from the Ledger/NC Health News about changes to the disclaimer. It was still posted in the app this week.
Fees allow docs to bill for their time
Holmgren said his research found that when a hospital added message fees, it led to a slight decline — about 2 percent — in the total number of messages sent.
The fees also lowered physician stress levels and seemed to boost their mental health, he said.
“In a lot of our physician well-being surveys, they’re saying that being recognized for this work has had a big mental effect,” Holmgren said. “Now, when you catch up on messages, you can bill for it and not lose out financially or lose out on productivity.”
Although there are always concerns about inflated billing practices in health care, Holmgren said the small fees a health care system can collect from messaging are not a strong financial incentive.
”This is one of the lowest reimbursements,” he said.
Many private insurance companies, in addition to Medicaid and Medicare, have started covering the messaging fees.
David Merritt, a senior vice president for policy and advocacy at the national Blue Cross Blue Shield Association, told The New York Times he was concerned that the fees “could easily be viewed and abused as a new revenue stream.”
Are other patients paying for refill requests?
After the Ledger/NC Health News asked Novant about Mahim’s bill, Mahim said the $41 charge disappeared from his Novant account. A billing representative told him on Tuesday it was being reviewed in response to his dispute.
Mahim said he could have paid the $41 charge but didn’t on principle.
He wondered how many other patients or their health insurers might have unknowingly paid for similar refill requests, adding that if he had already met his insurance deductible, he might have not even noticed the charge.
“They’re charging me and God knows how many other customers,” he said. “There could be a thousand other families getting billed through their insurance. In high volume, that’s millions.”
This article is part of a partnership between The Charlotte Ledger and North Carolina Health News to produce original health care reporting focused on the Charlotte area.
You can support this effort with a tax-free donation.
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