Billing for Patient Portal Messages in Dermatology: Trends, Policies, and AI

Conclusions

• Patient portal messaging has grown rapidly and now creates a substantial, often uncompensated clinical workload comparable to a clinic workload.
• Dermatology appears to be disproportionately affected by portal message and image volume, with messaging and attachment burdens outpacing face-to-face visit growth.
• Billing for portal messages is increasingly feasible and already adopted by many major institutions, suggesting it is becoming a mainstream workflow rather than an outlier practice.
• E-visit billing can modestly reduce portal message volume without clearly shifting demand to more office visits or telephone calls.
• Patient response to billing is mixed and may vary by demographic group, with some populations reducing messaging more than others and potential inequities emerging in access or response patterns.
• Billing may help acknowledge clinician time and potentially reduce unnecessary visits and wait times, but it also risks patient dissatisfaction, confusion about costs, and reduced access for some patients.
• Early evidence suggests the billing workflow is generally acceptable to clinicians and can be implemented with relatively little effort, though uptake remains low in many settings.
• Current AI tools can help draft portal replies but have only limited real-world impact so far, and their benefits are not yet large enough to meaningfully reduce inbox burden.
• In dermatology, human clinician responses are still preferred over ChatGPT-generated replies, implying AI is promising as support but not yet a substitute for expert clinical messaging.