The Medical Bill You Never Expected: Doctors Now Charge for Emails

More healthcare groups are charging fees to answer patients’ electronic messages, often the ones you exchange via their portal. Doctors say it’s only fair if they’re spending time on the messages and note that an email discussion can often save you the time of having to come in.

The typical cost of an email message claim was $39 in 2021, including both the portion paid by insurance and by the patient, according to a Peterson-KFF Health System Tracker analysis.

Some patients have been taken aback by the charges. They are surprised at the notifications on portals about the change, and irritated at the idea of a new fee.

Dr. Lauren Oshman, a family physician and associate professor at the University of Michigan Medical School, says she initially experienced some patient resistance and anger about the prospect of being billed for emails.

Now, she says, patients are typically pleased that they are able to get a direct response from her through a portal message.

“They’re thrilled when they get me directly," she says.

Doctors aren’t charging for every email. Federal guidelines typically followed by private insurers say that patients can only get charged for messages that require at least five minutes of a doctor’s time over the course of seven days.

Billable messages also have to involve some sort of medical decision-making rather than deal with an administrative matter, like scheduling an appointment, according to those guidelines. And emails that stem from a follow-up to a visit, such as explaining lab results, aren’t typically billed.

What that message will cost you

Health plans covered the full cost of about 82% of claims, according to the Peterson-KFF analysis. Patients who shared the cost paid $25 on average.

The practice of charging for emails has steadily increased in the past few years, as the volume of emails that patients send has grown. A 2020 ruling from the federal Centers for Medicare and Medicaid Services added billing codes that let medical providers get reimbursed for email correspondence that takes more than five minutes over the course of seven days and requires medical decision-making. That paved the way for private insurers that typically follow what CMS does.

Medicare generally reimburses physicians $15 for messages that take five to 10 minutes; $30 for those that take 11 to 20 minutes; and $50 for those that take 21 or more minutes.

Most patients with traditional Medicare plans won’t face any out-of-pocket costs, says A Jay Holmgren, an assistant professor in the department of medicine at University of California San Francisco and the Center for Clinical Informatics and Improvement Research. But people with commercial health insurance will pay something akin to a copay—unless they have a high deductible plan, in which case they will typically absorb the full cost.

A surprise in your portal

Jennifer Ann Falandys, a 41-year-old who lives outside of Buffalo, N.Y., says she typically emails her doctors at University of Rochester Complex Care Center once or twice a week. Falandys says she has cerebral palsy, lung complications and generalized anxiety disorder, among other things.

“Patients like me who are complex patients, we require a lot of interaction," says Falandys, who is a disability advocate.

“It just feels a little intimidating when you open the portal and the first thing it says is ‘be aware, we’re going to bill,’" she says. “We have to send these messages and we shouldn’t have to think to ourselves, ‘Should I send this?’"

The University of Washington Medicine health system started charging for patient emails over the summer.

The volume of emails has been growing over the past decade, says Dr. Crystal Wong, a family medicine doctor and associate chief digital officer at the University of Washington in Seattle. The system received 1.5 million messages through its portal in 2022, she says.

In just one morning recently, she answered 14 emails.

“I do this on my lunch break, I do this in between patients, I do this at night or in the morning before clinic," she says of responding to patient emails. “It is an amount of work that we need to acknowledge is real."

Wong says a small percentage of emails—only 1% to 2%—is billed. Those typically include medical issues that are safe to handle over the MyChart portal system, such as a rash with attached photos, or questions about a medication or supplement.

For more serious health issues such as acute abdominal pain, it’s important for patients to visit in person, says Wong. “I need to look at you and do a good old-fashioned exam," she says.

Emails that take time

Oshman of the University of Michigan said that if patient messages take her less than five minutes, she doesn’t bill for them.

However, some involve a back-and-forth that takes more than five minutes of her time over seven days. These may require her to review several past notes or another doctor’s notes and make a medical decision.

For instance, as an obesity medicine specialist, she may assess a patient’s response to medication and lifestyle changes and recommend dose changes. Or she might diagnose and treat a urinary tract infection, a rash, or manage treatment for patients with depression or anxiety.

“Out of every 10 messages, one or two of them are messages that take me a long time to answer properly," she says.

Write to Sumathi Reddy at Sumathi.Reddy@wsj.com