Finally, investigation fee is not "rebate in disguise".

I would like to draw members’ attention to the recently issued Newsletter of the Medical Council (Issue No. 18, October 2011).  (We received it by mail.  If you have lost it, you can go to http://www.mchk.org.hk/newsletter18.pdf and have a look.)  On page 6, under the section of “Advice/Information for All Registered Medical Practitioners”, you would find an article entitled “Guidelines on Charging Fees for Laboratory Tests”.  It started by stating that: “On 27 April 2010, the Chairman of the Medical Council issued a letter to all registered medical practitioners drawing their attention to a disciplinary case of a doctor charging a patient excessive fees for tests performed by laboratories…  The Medical Council considers it appropriate to provide further guidance to doctors on charging of fees for laboratory tests.”

My first impression was that: “What’s the matter with the Medical Council?  Why does it take one and a half year to clarify a letter issued by the Chairman?  Who can remember a case nearly two years ago?”  However, upon reading the article, I realized that many of us, especially doctors in private practice, would remember this confusing, if not wrong, judgment concerning “rebate in disguise”.  And, in fact this low-profile, half-hidden article was our long-awaiting rebuttal of the again confusing, if not wrong, message from the Chairman of the Medical Council.

Maybe let me dig up the relevant documents so that facts speak for themselves.  In August 2009, a doctor was found guilty of misconduct for charging his patient excessively for laboratory tests.  However, the judgment indicated that a comparison was made between what the doctor charged the patient and what the laboratory charged the doctor.  It then concluded at para 17 that “A doctor shall not receive any rebate from diagnostic laboratories or similar organizations to whom he refers patients.  A doctor must be honest and clear in setting out the charges to patients.  The differences in charges indicate that the Defendant Doctor has a financial gain from referring the Patient for laboratory tests.  This is a rebate in disguise.”  (http://www.mchk.org.hk/docs/STW_20090828.pdf)

Many doctors found the judgment against normal practice.  It ignored the fact that doctors had actually provided service in performing laboratory tests and they were entitled to charge their patients.  The Editorial of the September 2009 issue of the HKMA News made a thorough analysis of the case (No More “Laboratory Tests”!  (http://cm-mc-articles.blogspot.hk/2009/09/no-more-laboratory-tests.html). It pointed out that the inquiry panel should try to prove that the doctor actually did overcharge the patient.  It should not jump to such artificial and wrong invention of “rebate in disguise” principle.  It also urged the Medical Council to look into the case and to clarify queries from practicing doctors who were then at risk from the judgment.

Astonishingly, the response was given by the Chairman herself.  She did not put up any discussion in the Council.  Instead, in April 2010, she sent a personal letter to all doctors expressing her personal views (http://www.mchk.org.hk/letter_from_chairman.pdf).  Among others, the letter stated that “Arising from this case, the Medical Council wishes to impress upon members of the profession that the doctor’s own fees for professional services should be clearly separated from the fees collected on behave of laboratories for investigations.  If the doctor charges fees for his own services in connection with the investigations to be performed by the laboratories, the charges should be clearly set out and explained to the patient.”  Unfortunately, this letter served to complicate matter.  What the Medical Council said to impress upon doctors (but in fact was only the personal opinion of the Chairman; and it was later clarified by the Medical Council) was exactly what the profession disagreed.

In response to this confusing letter, the Editorial of the May 2010 issue of the News entitled “Dangerous Precedents” clarified this matter. (http://cm-mc-articles.blogspot.hk/2010/06/dangerous-precedents.html)  It pointed out that the letter posted a strict liability on doctors to explain charges to patients irrespective whether patients asked for it or not.  This was more than that of the judgment of the case.  This was also more than that stated in the Code.

No action was taken by the Medical Council or the Chairman of the Medical Council.  So private doctors had to work under fear and under uncertainty.  To avoid being caught by the ambiguity of the judgment, we had to add disclaimers explaining that every charge on the receipt should be interpreted as including, and not limited to, consultation, handling, professional judgment and advice, rental..., and virtually everything in the world.

It was only after one and a half year that came this piece of Guidelines.  Among them, the following three points were most relevant:

• 2. The Code does not require a doctor to itemize his own professional charges in invoices/receipts….

• 3. Section 12.1 of the Code stipulates that “Consultation fees should be made known to patients on request.  In the course of investigation and treatment, all charges, to the doctors’ best knowledge, should be made known to patients on request before the provision of services…”

• 8. A doctor may charge fees for all professional services rendered by him…  For an investigation, the whole package of services rendered by a doctor to a patient should be described in the invoice/receipt as “investigation fee ( 檢驗費 )”, in order to avoid any misunderstanding that the fee is collected on behalf of the third party.

From the interpretation of an average doctor (that’s me) on the plain and natural meanings of the Guidelines, the following points arise:

• The article points out that the previous letter from the Chairman contains information that needs to be clarified.
• Interestingly, the letter from the Chairman can still be found in the website of the Medical Council.
• There is no strict requirement to set out the items of charges and to explain them to patients unless patients ask for them.
• A doctor can charge more than what the laboratory charges him for tests.  He just needs to write down the term “investigation fees” in the receipt (and only if he chooses to do or as requested by his patient) so as not to cause any confusion.  In fact doctors rarely collect fees on behalf of a third party, such a laboratory.  Rather it is a common practice of the legal profession only.

(Source: HKMA News December 2011)