Don’t Be Surprised If Your Doctor Starts Charging You for Email

Dr. Pines is the Chief of Clinical Innovation, US Acute Care Solutions (USACS) and Clinical Professor of Emergency Medicine, George Washington University

Doctors are starting to charge for responding to email, and other offline tasks. Is it justified or just extra costs in an endless stream of medical bills?

It’s 6 pm and you might expect your doctor’s workday to be complete after a busy patient load. Yet for majority, work has just begun. It’s time to open their patient portal, review test results, answer piles of patient email. Then they do whatever needs to be done, like ordering more tests or consults.

Patient portals have improved access to test results and physicians. Day or night, you can review your results and pose questions such as, “What does this lab value mean?”, “Can you refill my prescription?”, “My x-ray shows a pulmonary nodule. What is that?”, or “Can I have a referral to see a specialist?” Patient portals have become an innovative and cost-free way for patients and doctors to communicate. Instead of dropping a co-pay for a traditional appointment or signing up a telehealth visit, a portal post often does the trick.

Here’s the problem: doctors are traditionally only paid for real-time encounters. There’s been no extra pay for responding to email or following up on many offline requests. Many doctors spend tons of time—often after hours—on unreimbursed activity.

Extra uncompensated tasks increasingly weigh down physicians spiritually and emotionally. Drowning in heaps of unpaid work, the toll is physician productivity, family life, and ultimately mental health. It is sometimes referred to as “burnout.” Others call it “moral injury,” creating a deeper and more complex psychological crisis.

Here's what changing: emailing in patient portals may soon not be so free anymore. In 2020, the Centers for Medicare and Medicaid Services (CMS) released a new billing code where doctors can charge for answering patient-initiated emails that require at least five minutes. Doctors can bill up to once a week per patient for total time spent. Excluded are emails related to scheduled appointments, refilling prescriptions, follow-up after procedures, or within seven days of a visit. The insurer then decides whether to pay for it directly or pass the costs onto the patient.

Read More: Why It Takes Forever to Get a Doctor's Appointment

A recent study of insured patients by the Peterson-Kaiser Family Foundation (KFF) found that doctors charge on average $39 per email. Patients with out-of-network benefits pay about $25 per email. Certainly, in the context of all the money we spend on healthcare, this seems nominal. But costs can add up if multiple emails are sent.

Yet, the KFF study found the frequency of claims related to patient portal emails to be low: averaging about 1 in every 192 office visit claims in 2021. This shows that in the first few years of the ability to bill, doctors hadn’t started charging patients.

Why? First and foremost, doctors may not want to alienate patients or disincentivize asking their health questions. Billing for portal messages may also be cumbersome, particularly because some messages are billable while others aren’t. Finally, some doctors may not even know you can bill for email.

There are reasons to believe that doctors charging for patient emails may catch on. One big driver is declining physician reimbursement. The amount doctors can charge for visits for Medicare patients has not kept up with inflation over the last two decades. There is also downward pressure on commercial payments through laws like the No Surprises Act (NSA), which outlaws balance billing. Billing for emails allows doctors to fill some of these gaps.

The KFF study found that in 82% of cases the insurance company just paid the bill. But as the frequency of billing ramps up, insurers will likely start passing on more of costs onto patients. 

Billing for patient portal messages also raises an ethical dilemma with doctors, specifically whether charges are justified. If we look at traditional business practices, it’s clearly reasonable. Working after traditional business hours and not receiving compensation violates labor law. Additionally with the advent of concierge medicine and other newer models such as direct primary care, subscription-based fees charged by such practice models will incorporate responding to email.

What’s clear is this: workable solutions, both ethically and economically, are necessary to address the deluge of communications—whether via traditional email, patient portals or phone calls—that physicians encounter.

Until the time comes that artificial intelligence (AI) can reliably and accurately answer patient questions and perform other important functions and tasks, physicians or their proxies will be required to empty their inboxes beyond the hours spent involved in direct patient care.