Going to the doctor now can mean coming away with a bill featuring a never-before-seen list of charges.

With health insurance companies cutting back on services they cover, doctors and other providers are passing on the unpaid costs to patients in the form of creative entries.

In some instances, patients find themselves being billed for the room they sat in while seeing a therapist, according to The New York Times. “How could it be that the doctor was in network and the hospital was in network, but I had to pay separately for the room?” Leo Boudreau, who found such a charge on a bill, said to the Times.

Some ophthalmologists are now charging “refraction fees” as part of eye examinations. A person with a broken arm is now billed separately for the sling used to support the arm in a cast. A visit to an emergency room can result in an “activation fee” being put on the invoice.

“In some cases, such as refraction, the services were never typically covered by health insurance but had generally been performed gratis as part of an exam,” Elisabeth Rosenthal wrote at the Times. “In others, the fees are novel constructs. In any case, as insurers and providers fight over revenue in an era of cost control, patients often find themselves caught in the middle, nickel-and-dimed.”

Some of the fees are for services that are supposed to be covered under the Affordable Care Act. Intrauterine devices are covered as part of the birth control mandate, but an “insertion fee” is charged. Annual physical exams are also part of the basic services provided at no charge, but some physicians are passing on the costs of the blood work, often several hundred dollars, to patients.

-Noel Brinkerhoff, Steve Straehley

To Learn More:

As Insurers Try to Limit Costs, Providers Hit Patients With More Separate Fees (by Elisabeth Rosenthal, New York Times)

Health Insurers Do End Run around Requirement to Cover Pre-Existing Conditions (by Noel Brinkerhoff, AllGov)

Worst Overcharging Hospital in U.S. (by Matt Bewig, AllGov)

Overbilling by Doctors and Hospitals Costs Medicare a Billion Dollars a Year (by David Wallechinsky and Noel Brinkerhoff, AllGov)