(MONEY Magazine) – When Anna Brown, a courtroom interpreter in Los Angeles, was charged $400 for blood tests while hospitalized for surgery last year, her husband Jack shrugged, since his insurance company was picking up the tab. But after the insurer returned the bill unpaid, claiming the tests were unnecessary, Brown, a producer of TV commercials, was shrugging no longer. He asked the doctor either to justify the charges or to drop them. ''He removed them from my bill,'' says Brown, who is now also challenging the surgeon's fee, which the insurer calls excessive. While most Americans would applaud Brown's assertiveness, few would probably feel comfortable imitating him. After all, most of us can talk to our physicians about the most intimate subjects (including our sex life), but there is something about the doctor-patient relationship that makes it hard to raise the matter of money. Yet it is hard not to worry about that issue these days. Physicians' fee hikes have exceeded the inflation rate for each of the past eight years, and employers and insurance companies are asking patients to shoulder an ever-larger share of the load. The average U.S. family spent $720 a year in unreimbursed medical expenses in 1980. By last year, that figure had nearly doubled to $1,300. Worse, since tax reform, only health costs exceeding 7.5% of your adjusted gross income are deductible. Of course, quality is still the most important criterion in choosing a doctor. But top drawer doesn't have to mean top dollar. Physicians' charges vary outrageously even within a single community (see the table at right). And the cost-management company that gathered this data, MedFacts of Miami, found absolutely no correlation between a doctor's fee and whether or not he was board certified in his specialty or trained in the U.S. or abroad. The point is not that a doctor's price is totally arbitrary -- it's set in part by his rent, staff and expenses -- but simply that you should not assume that he has no room to negotiate. Therefore, if cost is a serious concern of yours, you can't shy away from it. ''Don't be afraid to talk dollars and cents right from the beginning,'' says Dr. William Rial, a past president of the American Medical Association and now an executive at the Blue Cross/Blue Shield Association in Chicago. ''The more you look out for yourself, the better your care will be -- and that includes getting it at the right price.'' If you're looking for a new doctor, assemble a recommended list and then call the office of each to ask about his first-visit and subsequent fees. If you choose a doctor whose scale is reasonable, tell him when you meet that his pricing was part of your criteria. On the other hand, if you've already settled on a doctor you like but wish his fees were lower, point out your problem. Herb Cohen, lawyer-writer of the bestselling You Can Negotiate Anything, suggests that you send him some insurance reimbursement statements to show how much extra he is costing you. Or if his fees aren't out of line but you are having trouble keeping up, put together a brief account of your circumstances and a suggested payment. ''You needn't be belligerent or apologetic,'' says Cohen. ''Your aim should simply be to open the discussion.'' That's not the worst alternative for physicians either. ''Some patients change doctors without giving us a chance or, worse, they stiff us,'' points out New Orleans radiologist Daniel Johnson. ''That just forces up fees and makes it harder for the next patient.'' If your doctor won't budge, ask him if there's any other way he can help lower the overall bill. ''If it's testing, ask him if there's a less expensive way to get the same data,'' suggests Dr. Robert Becker, chairman of HealthCare Compare, a cost-management company in Downers Grove, Ill. ''For instance, for back pain, will a CAT scan do instead of a mylogram?'' By doing some research and mentioning cost cutting, you'll get your doctor thinking about the subject. That's helpful because physicians sometimes own the diagnostic facilities they use these days -- a questionable practice open to conflicts of interest. Your seeming knowledge and frankness are warning shots to the doctor that you are aware of current trends toward overtesting. Your feistiness may also encourage him to bargain for you with outside services and practitioners he recommends. ''Medicine lives on referrals,'' notes Wesley Smith, author of The Doctor Book (Price Stern Sloan, $7.95). ''Doctors often know who charges what and when to put in a good word for a better fee.'' Of course, when you have incurred a large bill -- say, for surgery -- it's hard to lower it after the fact. But not impossible. Observes Herb Cohen: ''The first thing to do is let the doctor know you take your responsibility very seriously, and chances are good he'll try to find a way to satisfy you both.'' This might mean a fee reduction, or there could also be other creative alternatives such as stretching your bill over installments, says Cohen. What if the doctor waves you off to his clerical staff and tells you to deal with them, not him? ''Don't force the issue,'' says Cohen. ''But don't deal with them, either. Write a letter to the doctor. Tell him you want to let him know how pleased you are with his services -- if you are. At the end, remind him that you need to discuss his fee, and tell him what you feel you can pay. If you get no reply and another bill at the full price, that's your answer,'' Cohen concedes, ''but it usually doesn't happen that way.'' As a last resort, and especially if you are unhappy with his treatment and not just his bill, you can always complain to the local medical society or state licensing agency, or take your case to arbitration. (Such routes of recourse are explained in the story on protecting your rights on page 149.) If you are still convinced that you have to be as brazen as ABC's Sam Donaldson to question a doctor about fees, consider this: about half the U.S. physicians already, in effect, offer discounts through pre-priced medical plans like health maintenance organizations. Why? Because they want the business and are willing to bargain for it. By 1995 that fraction is expected to swell to perhaps 75%. So remember, dear patient, when you dare to talk money with your doctor, the tide's on your side.

BOX: Check It Out The disparity is worth discussing

Maybe you'll feel less reticent about discussing fees with your doctor if you realize how dramatically they can vary for the same service. MedFacts, a cost- containment firm serving employers, uncovered the following four- and fivefold disparity in charges in one not atypical Florida county (Dade). The ''mid-range'' figure for the office visit is the median cost; for the surgeries, it's the ''usual, customary and reasonable'' fee as defined by insurers.

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