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A primary care clinic in Charlotte, North Carolina, has a sign stating that if a patient raises a concern beyond the original scope of the visit, they may be billed separately for doing so.

Atrium Health Primary Care Mountain Island certainly isn't alone in posting such a notice.

In recent months, a MedPage Today reader in San Antonio, Texas, flagged a similar sign at his granddaughter's pediatrician's office (which he did not name). And in Boston, a local woman was by Mass General Brigham.

While it's unclear if more clinics are posting such notices, billing patients separately for a single visit -- particularly a well visit where it's assumed there will be no cost-sharing -- isn't new. Patient advocates say they've been hearing about these issues for years, and technically, physicians are well within their rights to charge separately.

Caitlin Donovan, a senior director at the National Patient Advocate Foundation, told MedPage Today that she has heard about the issue repeatedly over the last 10 years. While the top gripe she usually hears about is finance, a close second is patients wanting to know how to get their doctor to listen to them.

"This kind of falls in the intersection," she said, noting that separate billing may give patients the impression that an office visit with their physician is simply a financial transaction, or that it makes them feel they can't raise important health issues during this time.

"I've heard of doctors not answering questions during appointments," she said. However, she noted that there may be more systemic factors at play, and decisions about billing may not be within the physician's control.

Providers' Perspective

The practice of separate billing appears to be commonplace among healthcare providers in a range of settings.

"Primary care offices may post signs about separate billing to alert patients that bringing up additional symptoms or issues during a visit may result in more cost-sharing, which the patient may not be anticipating," the American Academy of Family Physicians (AAFP) said in a statement provided to MedPage Today in an email. "This is not a new practice for physician offices."

"For example, when a patient has an annual wellness visit or physical, and the physician addresses something else, the physician would bill for an office visit in addition to the physical," AAFP added. "Cost-sharing is waived for the preventive service, but the patient may have a charge for the office visit."

A spokesperson for the American Academy of Pediatrics (AAP) also told MedPage Today in an email that separate billing is "not a new practice," rather a "broader reflection" of financial pressures affecting pediatric practices. These pressures include rising costs without increases in payment and the need to charge for additional services beyond the scope of traditional wellness visits.

In an online post, AAP detailed other reasons , including that their child's insurance plan isn't ACA-compliant, or the child received non-preventive services as part of the visit.

For its part, Atrium Health concurred with sentiments from the AAFP and AAP.

"Separate billing has been a common practice at healthcare systems around the country for quite some time," Atrium Health said in a statement provided to MedPage Today in an email, citing an example of "discussing a new skin rash or a pain concern during an annual physical exam."

"It is up to the patient if they would like to be seen for the new concern during their preventative appointment or if they would like to schedule another appointment to address it," the statement said. "Patients are notified of this policy at check-in."

Mass General Brigham did not return MedPage Today's request for comment on the issue of separate billing.

CMS Weighs In

A spokesperson for CMS told MedPage Today in an email that the agency is "aware of instances in which patients have been charged cost-sharing or other fees for items and services they received when they went to the doctor for an annual physical."

However, the spokesperson noted that "federal law does not impose any requirements on how providers code for items and services they furnish."

Federal law requires that most group health plans and health insurance issuers cover certain preventive services without cost-sharing when the services are rendered by a network provider, the spokesperson noted. also address when a plan or issuer may impose cost-sharing for an office visit during which a preventive item or service is provided.

Furthermore, HHS, the Department of Labor, and the Treasury Department have issued related guidance, the CMS spokesperson noted. The guidance states that, in addition to covering the required preventive service without cost-sharing, plans and issuers that are subject to the ACA's preventive services requirements must cover, without cost-sharing, items or services integral to providing the preventive service, regardless of whether the item or service is billed separately.

Overall, these statutory, regulatory, and guidance provisions are not new, and have been published for some time, the spokesperson added.

'Bring It Up Anyway'

Even if patients are troubled by the potential for separate billing, "I would say, bring it up anyway," Donovan said of any lingering health concerns patients may have during a visit with their physician.

"Most likely, there is something they can directly answer," she said.

"Let them tell you, 'No,'" Donovan added. And if there are potential barriers to care, such as not being able to take more time off work for another appointment or not being able to afford an additional visit, share this information with providers as well, she said.

"Patients should be very up front with their doctors with any financial issues they have," Donovan explained. Providers need to know about issues that are "pertinent to your treatment plan."

Open lines of communication may be particularly important as the practice of separate billing continues.

And the issue doesn't seem to be going away any time soon. Immediately after discussing the issue with MedPage Today, Donovan fielded another new report from a patient: Their dermatologist had posted a sign that each appointment is limited to three issues.

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