r/HealthInsurance • u/MenuRare9880 • Apr 28 '25
Claims/Providers Illegal to not bill through insurance?
I just got insurance for the first time in 3 years. My treatment that cost me $190 cash (self-pay) is now $520 until I meet my $3,500 deductible which would take me 11 months, soo.. pointless.
I told my Dr’s office I am no longer going to go through my insurance & the billing lady said that’s illegal… I am going to look for a new Dr now anyway but is there truth to this? Would I face repercussions as an individual patient if I simply chose not to disclose that I have insurance & pay the cash price?
FYI: the self-pay price was NOT subsidized by a grant or aid.
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u/bzzyy Apr 28 '25
If the office is in network with your insurance, their contract may require them to submit the bill to your insurance.
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u/Used-Somewhere-8258 Apr 29 '25
This is 100% the correct answer. Once they know you have insurance, they usually can’t just pretend like they don’t know anymore.
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u/Skippiechic Apr 29 '25
And they can/will use your SSN to find your coverage.
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u/lpcuut Apr 29 '25
I don’t give out my SSN to doctors offices, I don’t think most people do.
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u/hbk314 Apr 29 '25
They can likely acquire your SSN if they want to. Most people probably do provide it if the doctors office asks for it.
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u/Key_Employment4536 May 02 '25
I work in healthcare privacy. I refuse to give my Social Security number to any doctors office. You do not want to do this. You do not know how bad healthcare cybersecurity, but it is beyond bad. And I will tell them that to their face they have to give me a reason they need it and they’ve never been able to and that includes cosmetic stuff that I pay out-of-pocket
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u/Key_Employment4536 May 02 '25
Yes, they can. If I go to my doctor that I’ve be going to for years tomorrow and tell him I do not want the treatment for this condition to be sent to my insurance company they have to abide by that
now they can force me to figure out how I’m planning to pay for it standing right there, but they cannot tell me that they have to send it to an insurance company
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u/Key_Employment4536 May 02 '25
The contract with the doctors office cannot oversee override the federal privacy law
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u/Extension-Scar-5513 Apr 29 '25
As others said, it's not illegal. But it would be a breach of their contract with your insurer. They could face penalties or even be removed from your insurance company's network if they don't submit claims.
Another comment said to lie and pay cash price for your procedures then submit to insurance yourself. Do not do that. The insurance company will see that it's an in network provider and will then force the provider to submit the claim.
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u/guri256 Apr 29 '25
Are you sure? You are correct if the insurance company is private, but if OP has insurance through Medicare or Medicaid, I think it can literally be illegal.
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u/OneLessDay517 Apr 29 '25
OP described private insurance, so why would anyone answer as if it were Medicaid?
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u/pellakins33 Apr 29 '25
To be fair, someone reading the comments may have Medicare/Medicaid. If you don’t specifically call it out as an exception, you could be inadvertently giving them a misleading answer
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u/IcyHand8172 Apr 29 '25
Some people have both. Scenario is divorced parents with one unemployed with custody, but other parent has job with benefits and put kid on insurance. Private insurance gets billed first, Medicaid covers what’s left usually.
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u/Transylvanius Apr 29 '25
I don’t understand why the insurance company would care what or how you paid if there was no claim. They’d rather you made no claim anyway. They aren’t involved in the transaction. They aren’t making money on claims. A patient isn’t required to reveal if they have insurance are they?
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u/Emotional_Wheel_7140 May 02 '25
Insurance cares very much and has ruined doctors lives for giving a discount to patients or writing something off when their insurance didn’t cover it.
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u/pmpprofessor Apr 29 '25
Depending on the insurance medicare vs. medicaid vs. commercial vs. government insurance.
The government pays private insurance or subsidizes the insurance plans.
Order for government to give money to insurance company. The government wants a certain number of claims. If the patient does not use the insurance, start self paying. They won't be able to get the government benefits and payments. Moreover, patient higher usage means better negotiation power from the insurance side. Deductible means that if patients pay, that won't affect the insurance company. They still get money from the government and tax break. There is a need for certain threshold for insurance useage.
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u/Key_Employment4536 May 02 '25
So the contract says that it’s OK for them to break federal law. I don’t think so.
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u/Extension-Scar-5513 May 03 '25
What federal law? Insurance companies have contacts with the providers to join the network they are required to submit claims for our members and accept our allowed amounts as payment in full.
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u/goopstastic Apr 29 '25
hi there! i work in a pediatric office in registration & insurance verification. you are correct that for commercial insurance it is not illegal to self-pay (unless covered by medicaid), in fact it is considered a protected right you have with hipaa. consider the language you are using though:
there are several different classifications for self-pay patients. cosmetic, uninsured, total charges (for things like sports physicals), and hipaa protected.
if you request to be self-pay for a hipaa protected reason many offices will have an accompanying form (ours is called a protected health information form) that states you are waiving using your insurance and that you are self-paying for your own reasons (in training we describe this as a woman escaping abuse but is on the abuser's insurance, cobra coverage was cancelled but still running active, a teenager seeking reproductive care but doesn't want their parents to find out with an insurance charge, etc). YOU DO NOT HAVE TO DISCLOSE AS TO WHY YOU WOULD LIKE TO BE SELF-PAY. it is your right under hipaa to ask providers not to disclose your PHI (protected health information) to your insurance company and assume all personal financial liability.
my suggestion to this provider would be to request self-pay rates due to hipaa concerns and state that you have no issues signing a form to not use your insurance. do not back down. this is a right given to you under hipaa that you do not have to have your PHI disclosed to anyone without a written agreement (typically in registration forms).
feel free to ask me anything else or if you need clarification!
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u/Weeping_Willow_Wonka Apr 29 '25
I just appreciate that you spelled HIPAA correctly 😆
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u/goopstastic Apr 29 '25
it would definitely discredit me if i did not 🤣. it SHOCKS me how many people that work in the medical field that are not familiar with the actual acronym.
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u/krysteline Apr 29 '25
I just went to a new dentist for the first time and the HIPAA forms were spelt HIPPA in various places and i cringed. I dont even work in healthcare haha
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u/DNAfrn6 Apr 29 '25
I never thought of the reasons you listed that might cause a person to self pay. Thank you for the information! It certainly broadens my understanding of how individuals interact with the health insurance system.
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u/goopstastic Apr 29 '25
happy to help and educate! unfortunately these classifications are not usually presented transparently which is why most people don't consider them. as i've learned as a patient and an employee in the american healthcare system, it's often all in the way you word it and knowing what your rights are. unfortunately, a lot of people who are placed in billing and insurance verification positions do the bare minimum and do not care to remember how to best help the patient. in my eyes, i exist to bridge the barrier to care and to connect the patient to the best healthcare possible. that includes whatever financial situation suits them best. ❤️
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u/DisastrousEvening949 Apr 29 '25
Came here to mention this. I’m a nurse, not an insurance expert, but we’ve had to frequent HIPAA trainings, and questions often came up about patients who want certain things to remain self-pay. I don’t remember the exact names for the process, but I do recall someone mentioning that they had a patient who didn’t want their lab results released to their insurance company, so they asked to have it done self-pay. (It might have been something related to PHI disclosure being allowed for pursuing payment? The idea being, if they self-pay, there’s no further payment to pursue or bill to insurance. Therefore if insurance doesn’t have access to the lab results, it can’t be used against them later? For this guy specifically, it was years ago, he didn’t want his A1C disclosed, as it could impact future coverage/waiting periods if the result indicated diabetes. Iirc it was from a time when preexisting conditions were a hard limit and could make someone ineligible for coverage in the event of a lapse). I don’t remember what the answer was - if this would be successful, or realistic.
Anyway, I do recall hearing that the option to self-pay is available for ppl with non-Medicaid plans
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u/MenuRare9880 Apr 29 '25
thanks so so much. Do you know if the different classifications of self-pay subsequently have different $ rates? Some ppl have told me I can do self-pay but I’ll just be charged the same rate as insurance anyway
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u/goopstastic Apr 29 '25
it differs from clinic to clinic and hospital to hospital. in my clinic, we still provide the discounted rate IF they pay in full at time of service. if you don't pay at time of service and choose to be billed, then often the discount goes away. i would honestly be surprised if they didn't provide the discount for hipaa protected reason because we aren't entitled to ask why you are self-pay. typically, cosmetic self-pay and self-pay total charges are the two we bill in full for.
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u/Constant_Demand_1560 Apr 29 '25
Thank you so much for this information! Does this also apply to non opioid prescriptions? I self pay for a medication and the pharmacist last time gave me hell for wanting to pay for it myself, has never happened before. Every month I tell the pharmacy to delete my health insurance and not to bill it and every damn month, they still do. Is there a way to permanently stop them from doing that?
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u/goopstastic Apr 29 '25
i will be transparent that i am unsure if it is a covered right for pharmaceutical benefits. dental, pharmaceutical, vision, and medical insurances and providers have different requirements under hipaa.
i do have a close friend who works as a pharmaceutical tech at a retail pharmacy. she has disclosed to me before that they take self-pay patients often and it is not unusual for patients with insurance to opt to be self-pay.
as far as the pharmacy having your insurance information, sometimes that is not our choice depending on the verification system set up with the EHR (electronic health record). we personally use a program called eCare through experian, and these programs are set up to "find" the insurance and can fight us when we override to insert self-pay. i will do some more research and ask around to see if i can find more information on the topic as it applies to pharmaceutical benefits!
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u/pellakins33 Apr 29 '25
I have several scripts I run through GoodRx instead of my insurance. It’s way cheaper to just pay cash than have it hit my deductible
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u/Sad-Contract9994 Apr 29 '25
You seem to know a lot! This is completely off-topic but I’ve always wondered and maybe you have random knowledge. Why is it that Rx data is exempt from HIPAA such that private companies are able to buy this data and that doctors are able to buy into a service that provides it? I am even surprised when one entirely unrelated provider has access to a database of Rx for a patient that is not part of a controlled substances or tracking program (like scheduled meds, Accutane, pseuphedrine, etc)
This came back to my mind with the news that HHS is considering using commercially available data on Rx to help its catalog of those diagnosed with Autism (the implications of which I am not including here bc I don’t wanna make a stir..: but I think it’s obvious how I feel about that.)
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u/goopstastic Apr 29 '25
well now you've sparked a new area of interest for me! pharmaceutical, dental, vision, and medical benefits are all subject to different requirements under hipaa. my best guess without any prior research would be that there is a loophole in pharmaceutical benefits that are not subject to the privacy rule under hipaa. unfortunately, pharmaceutical companies and representatives are ruthless and are only in it to make an extra buck. we actually had to ban pharmaceutical representatives from coming into the office to do anything except leave information.
as far as RFK's autism registry he'd like to create, it would be a violation under hipaa since it is a medical diagnosis unless the patient volunteered to share this information with the state/federal governments. this is the issue he will run into to mandate the registry. my best guess is that he wants to pull from the RX catalog since it is not subject to the same regulations, but i don't know how he would realistically be able to bypass hipaa with even that loophole.
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u/SafeLongjumping2712 Apr 30 '25
The correct answer. You can always self pay. You dont have to use your insurance.
Clarifaction. Was the initial charge higher and then u got a self pay discount. There should not be different charges to any insurance or to you.
The insurance can then make an adjustment. I suspect your cash price is adjusted. You may not have been told.
Your states insurance department should be able to walk u thru it
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u/laurazhobson Moderator Apr 29 '25
The issue is that non-lawyers often misuse the term "illegal" to describe civil issues - e.g. contractual issues
Many insurance companies do not permit providers in their network to circumvent insurance with a cash rate. It is a breach of a contract but not "illegal" which is a criminal offense.
Medicaid is completely different as providers in most states are not allowed to charge Medicaid patients anything - even if they don't accept Medicaid.
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u/cballowe Apr 29 '25
Civil violations can be illegal - speeding is illegal, but not criminal until it's extreme. The main difference is whether the violation could lead to jail. (Oversimplified)
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u/dadayaka Apr 29 '25
While not illegal, it may be against their contract with the insurance. Medicare and Medicaid contracted providers are almost all prohibited from taking cash patients who have those insurance plans. Since those are government funded insurance it can be seen as illegal (though I dont know if thats the right word to use).
Other insurance plans may have contracts that dictate the same stipulation and could cause the insurance to stop working with that provider. If its a big insurance network they will do (and often say) almost anything to stay compliant with that contract or face loosing thousands of patients.
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u/Key_Employment4536 May 02 '25
If I have signed the contract that says they have to break a federal law then there are so stupid you probably should not be receiving medical treatment from them.
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u/OneLessDay517 Apr 29 '25
If you presented your insurance to them and they are in-network, it would violate their contract to not send it through insurance. It's not illegal, she used the wrong terminology.
If you want to avoid using your insurance, then don't present your card. But by self-paying, you will NEVER hit your deductible. If you have a large expense, you're still going to have to pay that full deductible before insurance kicks in.
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Apr 28 '25
[deleted]
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u/Working_Coat5193 Apr 29 '25
Medicare providers have to opt out of Medicare. It is illegal to charge a Medicare patient without running it through the program.
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u/LuluGarou11 Apr 29 '25
Even Medicaid patients can self pay. It is not illegal.
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u/999cranberries Apr 29 '25
It's not criminal but it is often a violation of the provider's contract with the state and the contract the patient enters into when they enroll as well. So in that sense there can be legal consequences.
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Apr 29 '25
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u/LuluGarou11 Apr 29 '25
Gtfo with your nonsense. It is not illegal in any state much less many states. If your practice is so greedy as to refuse self pay pts thats on you.
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u/nik_nak1895 Apr 29 '25
It's not illegal. It's a violation of their insurance contract if they ask you not to use your insurance. As the patient however, you can request to opt out of using your insurance. They need to have you sign an opt out form.
Just know that you will not meet your deductible, and whatever other providers you see you will end up facing the same issue so often it is better to pay the deductible.
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u/positivelycat Apr 28 '25 edited Apr 29 '25
Not illegal but many view it as a violation of the insurance contract.
Now they can not bill your insurance but they do not have to offer you the cash rate and can bill you the full insurance rate.
They would also likely require you sign something prior to service that says you will not bill insurance.
That is were the fraud/ dishonest part comes in some patients have been know to try and pay self pay rate then turn around and bill insurance or cry wolf 8 months layer that they should have billed insurance...
We won't do it cause to many people try to bill there insurance or claim we should have and then we get in a pickle with insurance.
Edit also we may find your insurance especially if we already have it..
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u/MenuRare9880 Apr 29 '25
shit so even if i go to a new Dr who I don’t provide my insurance to, they can still find my policy??
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u/positivelycat Apr 29 '25
Sometimes, the question is will they even look.. you roll the dice on that one
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u/Alternative-Sweet-25 Apr 29 '25
Yes that’s correct.
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u/LuluGarou11 Apr 29 '25
You are incredibly misinformed.
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u/Alternative-Sweet-25 Apr 29 '25
I work for Medicaid so no I’m not. But please tell me how if a Medicaid patient tries to self pay they can’t be kicked off of Medicaid.
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u/LuluGarou11 Apr 29 '25
You are straight up wrong. This is frequently done. ACA even set provisions in place to protect people from misinformed people like yourself denying them their rights. Sorry you suck at your job.
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u/Alternative-Sweet-25 Apr 29 '25
If I’m so wrong prove it.
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u/LuluGarou11 Apr 29 '25
Burden of proof is on you to prove its illegal. You cant. Many different laws protect patients here. One such being the HITECH amendment to ACA. Its not unusual for greedy billing departments to pretend their preference is the law. Do better.
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u/positivelycat Apr 29 '25
The hitech act does allow you to not bill insurance but it also allows the provider to collect full fees upfront and not offer the self pay discount
Which defeats OP purpose.
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u/LuluGarou11 Apr 29 '25
As per the title, OP wanted to understand if it was “illegal to not bill through insurance?”
Thus my point that self pay is an option. And certainly not illegal as so very many suggest on here.
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u/NoMagazine9243 Apr 29 '25
The OP did not mention Medicaid. You are correct as it relates to private and commercial insurance. You may even be correct RE Medicare, but Medicaid is different. If a person is on Medicaid (or discloses to a provider that they are on Medicaid), some are not allowed to provide any services to that person, including for cash (eg MIDI is a good example). I’m only a consumer and do not work in healthcare or insurance, but I’m absolutely certain the rules are different for Medicaid as a gov’t funded program.
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u/LuluGarou11 Apr 29 '25
Okay, dunning-kruger. Sorry you are also certainly incorrect.
You really need to further educate yourself on the nuances of the law vis-a-vis what is legal and what some providers choose as their preference. Medicaid patients are fully within their rights to self pay for care not covered by Medicaid. Different states may have different processes for achieving this OON status (aka paperwork) and providers do have their own billing priorities and policies (some of whom prefer the usually higher reimbursement rates offered by health insurers), but it is still legal and common. Further it would be a violation of HIPAA for your provider to disclose to any external private party any healthcare services rendered that are not relevant to said third party. The medical service is between the medical provider and the patient. Brazenly trying to double-dip and claim in network healthcare benefits on a service contracted out of network is a whole different thing.
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u/hbk314 Apr 29 '25
A healthcare provider can absolutely find OP's policy even if OP doesn't provide it to them. The chances of it happening depend on how big the insurer is. People with UHC are going to be a lot easier to find than someone with a smaller, regional insurer.
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u/LuluGarou11 Apr 29 '25
Please disregard these people telling you you cannot self pay. They are very wrong.
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u/NoMagazine9243 Apr 29 '25
Humbly, you are correct as it relates to private and commercial insurance. You may even be correct RE Medicare, but Medicaid is different. If a person is on Medicaid (or discloses to a provider that they are on Medicaid), some providers are restricted from knowingly providing any services to that person, including for cash (eg MIDI is a good example). I’m only a consumer and do not work in healthcare or insurance, but I’m absolutely certain the rules are different for Medicaid as a gov’t funded program.
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u/Key_Employment4536 May 02 '25
They probably should read the contract before viewing it as a violation. Because in the contract there is a clause related to compliance with federal regulations.
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u/lemonlegs2 Apr 28 '25
Wow. I can't believe they told you that. It is very legal. Majority of my life I've done cash pay because I have crappy insurance. Most doctors will not back a bill out after it's been submitted to insurance. But for future visits, either tell them you lost your insurance or if they have a better billing person tell them to denote as self pay.
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u/sicnevol Apr 29 '25
It’s not legal if it’s Medicare or Medicaid. They have billing contracts.
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u/lemonlegs2 Apr 29 '25
My understanding is majority of people on those programs do not have deductibles, definitely not 3.5k deductibles. Hence the assumption it is private insurance.
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u/sicnevol Apr 29 '25
Depends on the state. Some people have monthly spend downs, but not deductibles.
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u/MenuRare9880 Apr 28 '25
I understand them not being able to back the bill out & I’m willing to pay the $520 this one time. But they would not let me go back to self-pay knowing my insurance is still active 😞
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u/Particular-School-15 Apr 29 '25
That is also correct once the claim has been submitted you are bound to that process. However moving forward you can choose to not use your insurance. I always ask what the cash price is
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u/lemonlegs2 Apr 29 '25
That's dumb. Either it's an extremely shady practice, or a very uneducated billing person. The latter is the norm. I'm not sure how medical admin staff are selected..
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u/DazzlingPen5460 Apr 29 '25
You should call them and say that you would like to report that your insurance is no longer active and to ask them to remove your insurance information from the system. Say that you will not disclose any further information about your insurance status per HIPAA's protection of patients from being forced to disclose insurance status, and if you want to play hard-ball, just let them know that if they want to prod here you're happy to file an investigative req into their office with the Office of the Inspector General (who investigates HIPAA violations)
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u/WorryFar7682 Apr 29 '25
Work in healthcare. Not illegal.
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u/Particular-School-15 Apr 29 '25
This is the correct answer. You can opt out of having your insurance billed and pay cash
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u/ResearchWise3593 Apr 29 '25
All depending on the policy and contracts of the individual clinic/system.
I work in a system that does not allow self pay if there is insurance to bill.
I do work in family medicine though, so there are limited procedures, and most patients insurances cover primary care prior to hitting the deductible
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u/Alaskadan1a Apr 29 '25
But in most cases, if you pay cash and opt out, then it does not go toward your deductible. So eventually, if you actually had substantial bills, you’d still have to pay down your deductible before your insurance would start covering the next part.
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u/MSPRC1492 Apr 29 '25
It’s a racket. Having insurance doesn’t help with medical costs. It makes them higher.
People need to accept this and stop playing the game.
I cancelled my old policy and told my doctors I’m now uninsured. I bought a policy where I have to pay $6,500 out of pocket before it pays a dime- and told nofuckingbody. It will never be used unless I have a serious emergency, and not “I need a mammogram” emergency, but an I’m airlifted off the scene of an accident emergency in which case paying $6,500 won’t be my biggest problem.
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u/Alternative-Sweet-25 Apr 29 '25
$6500 is a drop in the bucket when it comes to healthcare costs.
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u/MenuRare9880 Apr 29 '25
This is what I’m going to do once I find a new provider. Do you think there’s any way they can find out you have insurance & you get in trouble??
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u/MSPRC1492 Apr 29 '25 edited Apr 29 '25
No. Make sure the new provider is at a different system, not associated with the one you gave your insurance to. But even if they somehow found out you had insurance you won’t get in trouble. The rule she was referring to applies to them, not you.
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u/Working_Coat5193 Apr 29 '25
It might be illegal if they didn’t provide you with a good faith estimate which requires more work on the office.
You need to speak with the office manager or billing supervisor
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u/bmfitz Apr 29 '25
I accept insurance for behavioral health and I can still accept cash pay. As far as I know no one can force someone to use their insurance or a provider to bill it if the client requests to pay out of pocket. The only thing that would be a breach of my contract [specifically] would be if I refused to take their insurance and would only accept cash pay. The only caveat is that if someone pays out of pocket lower than the contracted rate it can’t go towards a deductible or out of pocket costs. I can’t vouch for other insurance contracts though, only mine.
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u/InterestingFlight725 Apr 29 '25
I had something like this happen recently to me. If you tell the hospital that you're going to self pay before the procedure (before insurance is billed), they are required to honor this under the HITECH Act of 2009 (Google it if you don't believe me). It's basically protecting you as the patient from having your PHI released to insurance, which is protected also by HIPAA. This is assuming you're in the USA.
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u/Naive-Garlic2021 Apr 29 '25
I've gotten PT before on a cash basis because I had a huge deductible I didn't expect to meet. Maybe it's up to the practice?
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u/NoMagazine9243 Apr 29 '25
Just fyi—this is important to understand/realize if/when you choose to seek out select imaging to proactively manage your own health (eg DEXA bone density, DEXA body comp, CAC ie coronary artery calcium). If you approach imaging center and advise them that you do not have commercial insurance, you can usually negotiate a fantastic cash pay rate. ***For example, for the CAC—under my plan, the test was considered an “advanced image” so my in-network co-pay was $400! Without insurance, the imaging center offered the scan for between $89-99! I paid $99. I was offered a similar price for a DEXA bone scan and $60 for body comp. The important part is not to disclose that you have commercial insurance of any kind, otherwise, the imaging center will insist on billing your plan regardless of whether they are in or out of network (in my experience).
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u/lemonlegs2 Apr 29 '25
Yeah I had an mri done a few years ago. Cash pay was 250, insurance negotiated rate was 3k. Called many places.
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u/DefrockedWizard1 Apr 29 '25
yes, it's all part of the insurance scam so you can't afford to have it and you can't afford to not have it
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u/Burnsidhe Apr 29 '25
How would they know you've met your deductible if you don't tell them what the charges are by submitting a claim?
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u/DesignsbyMo Apr 29 '25
I want to read the comments so I can learn, how come I cannot read the comments?
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u/RetiredBSN Apr 30 '25
Is that what the doctor is billing, or is that what’s left for you to pay after the insurance applies their discounts and pays their part? If it’s what’s being billed by the doctor, I’m pretty sure that’s not going to end up being what you pay. You should get an estimate of benefits (EOB) from your insurance showing 1) what the doctor is billing; 2) the amount the insurance considers reasonable and customary (and what they have contracted to pay the doctor); 3) the amount of the bill they paid; and 4) the portion of the bill that you owe. EOBs are sometimes
A doctor may bill whatever he wants, but insurance is going to limit that to the customary amount, and even if the insurance is not covering anything, your payout should not exceed what the insurance company allowed.
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u/Highstakeshealthcare May 01 '25
You can absolutely elect not to use insurance. This system is so flippin' corrupt. The law is that you can choose to not use insurance but then the same government allows "network contracts" to dictate to a provider that they cannot offer lower rates than the contracted rates to its members. Everybody seems to think, because they are told, that network discounts are always less than cash pay which is incredibly wrong. Network discounts are not discounts at all. I own a TPA and administer plans and took all of my employer groups out of all networks several years ago and their costs (the employers) have dropped to below half the national average and they still offer $500 deductibles, 80/20 coinsurance with $1500 max OOP. The health insurance game in this country was designed to be one that you never win. I personally opted out of their games several years ago. I have a backup plan in case of major events but I cash pay for everything else. Fortunately, I am healthy at 58 but I also know how to audit a claim and not pay for egregious charges, bundled charges, etc. You can't even do that with networks - they want claims paid as charged and most all of the claims have errors that are never in favor of the patient. It's a racket - all of it. If you must have insurance, keep that card hidden unless it's a dire emergency. The charges and payments won't apply to your deductible but if you never hit your deductible anyway, then you win.
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u/Emotional_Wheel_7140 May 02 '25
Get this, I worked for a dental office that was charged with insurance fraud and dentist was faced with jail time. Because they wrote off what a patient owed them. Say the dentist wanted X-rays and it’s not covered by insurance. So they wrote it off. That’s illegal and could face jail.
“Being found guilty of perpetrating fraud can result in fines, loss of network participation and professional licenses and even jail time.”
If an office is in contract with your insurance. You have them insurance and the contract has a set price, they now are not allowed to offer anything different. It is illegal and they could go to jail.
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u/Emotional_Wheel_7140 May 02 '25
Tbh no one is going to look into this office for offering lower prices to cash pay patients. You didn’t have insurance so they gave you a cash option. But they obviously are raising the prices for people with insurance because they know insurance isn’t going to pay much anyways, so it’s how they fix the difference. The moment you have your insurance they could no longer offer you that low price because they are in contract with that insurance for a higher payout. It should be okay for offices to offer lower cash prices. But it technically should only be a 10% difference. So now they can’t allow your record to be able to play that cash price because if they ever get audited by the insurance company you use they could be charged with fraud and face jail time and lost license . Unfortunately practices are trying to offer lower prices for cash patients because they don’t cost the staff time chasing insurance. But once insurance finds out they are offering cash patients lower prices than to them they will come for that office and it is illegal.
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u/Key_Employment4536 May 02 '25 edited May 02 '25
Sam, I got your legal degree from the Holiday Inn express last night didn’t you
Is other people who have worked in the healthcare industry have pointed out, but some of you were posting about the contracts, and the law is wrong.
The law of governance is HIPAA and it says if you tell them to bill you directly, they have to do that. if you tell them, you don’t want your family member your insurance company or anybody else to know about you treatments They have to do that. They’re not going to do this because it’s going to cost them money not because it’s illegal. They’re making a lot more money off the combination of the insurance and the co-pay then they were the self-pay discount they were giving this person. And no now that they know you have insurance, they’re not going back to giving you the self-pay discount so your options are suck it up or find another provider. and pay it out of your pocket
Now, if you tell them, you don’t want to bill insurance they are within their rights to tell you you have to pay upfront or provide another method to guarantee payment. For example, we did this with a car accident and I had to give them a credit card they could charge if my car insurance company did not pay
The original poster can tell this doctors office that you are going to report them to the office of civil rights at the Department of health and human services for a violation of your HIPAA rights if they continue to bill your insurance company as you have asked them not to provide that information to that entity. That is allowable. Unfortunately you cannot force them to go back to that great deal you were getting before so you’re probably going to wind up paying the whole amount out of pocket, including what the insurance company is currently paying and your current co-pay so make sure you want to do that before you make this announcement. They don’t have to give you that self-pay discount they’ve been giving you.
And having worked on both sides of the table, the insurance company doesn’t really care. They would just assume you kept paying $190 and they never saw a claim but …. and the insurance company is not having your MD sign a contract that puts both the MD and them in violation of a federal regulation.
Here’s a short resource, but there’s an entire collection of
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u/chrysostomos_1 May 03 '25
My in network provider asks whether I want to bill insurance or pay personally.
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u/DazzlingPen5460 Apr 29 '25
Def NOT illegal for you!
The providers office would be the ones in hot water---THEY would be breaching their contract with your insurer if they knew you had insurance and then accepted your cash pay. But that is their problem, not yours
You are 100% within your rights to say that under HIPAA, you choose not to disclose your insurance or insurance status and are going to be self-paying (insurance status is protected under HIPAA). Saying this is a) valid / true and I've found b) throwing that around makes front-desk people antsy of a HIPAA violation and stop asking questions around self-pay eligibility
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u/Waste-Text-7625 Apr 29 '25
So is the $520 what you owe AFTER the bill was reduced to the insurance companies' contracted rate? Most of those rates are lower than what cash would be. Or was the $520 what you saw submitted to your insurance company? If so, wait until you get your EOB showing what the patient responsibility is. The doctors office can only bill the contracted rate and can not balance bill you for the remainder. So even though insurance won't pick up the tab, it usually works in your favor as you pay what their contracted rate is, which is usually very favorable.
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u/MenuRare9880 Apr 29 '25
The contracted rate is $520, which is what I owe since I have not met my deductible
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u/lemonlegs2 Apr 29 '25
Most cash pay rates are about ten percent of what negotiated rates are.
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u/Waste-Text-7625 Apr 29 '25
Your math doesn't compute in this case. Furthermore, i have never found a doctor (for regular visits) who charge less than insurance rates (especially mental health providers). Maybe you are just lucky in the area where you live or are talking about negotiating with hospitals for procedures, which may be way different than an ongoing charge that the OP is discussing in a non-hospital setting.
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u/lemonlegs2 Apr 29 '25
Nope. Why would you say math doesnt compute? I'm in an industry with bad health insurance. Ive never in my life had a bill be lower with insurance - perhaps the hospital birth of my child, burritos I wouldn't be surprised if that's cheaper cash as well. Everyone I know uses cash pay rates unless they are intending on having a large medical year. I think in 2025 it's more common across the board for cash to be lower and good insurance is the anomaly. Just a plain old thyroid lab for example, without insurance I can get for 25 dollars. With insurance it's 80. Had a baby 2 years ago labs with insurance- 2200, cash pay 350. Ultrasounds with insurance - 900, cash pay 150. On and on. When I was seeing physicians more regularly itd be around 300 after insurance, or 125 cash pay. My OB charges 2.5k without insurance, 7.5k with. My negotiated rate was like 6k. Ive seen a plain old therapist. 125 after insurance, 100 cash pay - true, smallest difference for that service.
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u/Waste-Text-7625 Apr 29 '25
So all my labs are much cheaper than Quest cash rates. They aren't even close. Doctor would be 50 percent more with cash. There is no way YOUR purchasing power is better than most networks. If you shirk in premiums and buy crap insurance, well, you get what you pay for. That is why sometimes going with a low premium is not a good deal for those who actually will use their insurance, even with a higher deductible.
But again? Just because you had a certain experience doesn't mean yout bullshit made up statistics like 10 percent cash costs is ethical or appropriate to post.
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u/lemonlegs2 Apr 29 '25
Again, I have talked to many people, in many different locations, across several networks. It is normal for cash pay rates to be cheaper. The problem is medical charges reasonable rates for cash, then a huge markup to insurance to ensure they don't miss out on any dollars. For example, my lab that was 350 cash or 2200 after insurance. They initial bill to insurance was 10k. They would never quote that to a cash pay patient.
I don't understand why this sub loves health insurance and thinks anyone with a bad experience is a moron. I guess everyone here works in insurance?
We pay 550 a month in premiums for the best plan we have access to through UHC, previously BCBS. My company's policy, which I don't have anymore, is 1100 a month in premiums. And has been quoted by a provider as "the worst insurance they've ever seen". High premium does not automatically equal good negotiated rates and coverage.
It's great you have great insurance, but that's not the norm.
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u/sneesnoosnake Apr 29 '25
In-network: They have to bill insurance first and they have to accept contract/negotiated rates. If they don’t bill insurance first before billing you then you have no visibility into negotiated rates and no way to make sure they aren’t balance billing, or charging you the difference between the negotiated rates and full retail. So at best they are just trying to save themselves the hassle and cost of billing insurance, at worst they are planning to hoodwink you into paying their full retail pricing. Another reason you want things billed through insurance is that it is the only way for it to count against your deductible. Drop that Dr office like a bad habit.
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u/Ladydi-bds Apr 28 '25
Can self pay anything. Just tell them you dropped your insurance the next time you go.
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u/MenuRare9880 Apr 28 '25
The billing woman pressed me for a lapse date on my insurance & wouldn’t let me keep my appointment without it 😞
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u/LuluGarou11 Apr 29 '25
Lots of people who are bad at their jobs. They also tend to find themselves in admin positions... just saying..
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u/YayVacation Apr 28 '25
Pretty sure that’s only if you have Medicaid. I was told the same thing before even though I had paid cash price a few other times and the person who told me ended up being wrong.
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Apr 28 '25
[deleted]
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u/RockeeRoad5555 Apr 28 '25
Some provider/insurance contracts may preclude this but it is only illegal for Medicaid.
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u/LuluGarou11 Apr 29 '25
Not illegal for medicaid either.
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u/RockeeRoad5555 Apr 29 '25
Probably varies by state.
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u/LuluGarou11 Apr 29 '25
Nope. It does not. It is not illegal.
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u/RockeeRoad5555 Apr 29 '25
If the provider participates in Medicaid, it is.
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u/LuluGarou11 Apr 29 '25
You are mistaken.
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u/RockeeRoad5555 Apr 29 '25
I would advise anyone reading this to do their own research and not trust either one of two arguing commenters on Reddit, neither of whom are providing sources.
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u/Alternative-Sweet-25 Apr 29 '25
Not illegal per se but it does violate the contract with Medicaid and the patient can be kicked off.
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u/LuluGarou11 Apr 29 '25
That is not true.
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u/Alternative-Sweet-25 Apr 29 '25
Yes it 10000% is true.
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Apr 29 '25
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u/Weeping_Willow_Wonka Apr 29 '25
More likely the provider would get kicked off than the patient, the patient doesn’t have a “contract” per se with Medicaid but the provider certainly does. The type of fraud that might cause a patient to be kicked off is more like let a neighbor use their Medicaid card to go to urgent care or something
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u/MenuRare9880 Apr 28 '25
I’m ok with it not going towards my deductible as long as I get the cash rate (ie: the $190 in my case) but this Dr won’t let me do it. Thank you!
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u/buzzybody21 Apr 28 '25
There’s nothing illegal about this. Does the doctor take your insurance, or are they charging you the cash price because they don’t?
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u/MenuRare9880 Apr 28 '25
They do take my insurance, but my insurance won’t cover it until I meet my deductible.
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u/buzzybody21 Apr 28 '25
So essentially, they’re billing your insurance toward your deductible, instead of giving you the cash price? Nothing illegal here unfortunately.
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u/devanclara Apr 29 '25
Since they are claiming it's "illegal" I would ask them to site which statute it violates.
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u/Emotional_Wheel_7140 May 02 '25
It’s a violation with their contract with their insurance. If patient shows their insurance and the office runs it. They cannot as an office not now abide by the insurance contract. It’s called insurance fraud.
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u/Anxious_Win7381 May 02 '25
Odd, because I was in physical therapy, using Medicaid and whenever I checked in using MyChart it gave me an option to not use my insurance. Hubby has his PCP in the same network and it asks the same thing, and he's on Medicare. We laugh about it every time we see it, because why would we want to be billed without our insurance? Ohio, BTW.
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u/Emotional_Wheel_7140 May 02 '25
Weird …”Medicaid recipients always have the option to self-pay for services not covered, but they cannot self-pay for services that healthcare coverage will pay for. In other words, this gets to the heart of the issue: You can't self-pay for a service that Medicaid will cover”
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u/LuluGarou11 Apr 29 '25
Haha no it is not illegal. Billing lady is misinformed/incorrect. This is common practice. Maybe talk to a supervisor of hers at the practice who knows better. Best case this doctors office has a policy where they refuse to take self pay, but not because it is illegal or not commonly done. Worst case billing lady is not only wrong but also aggressively wrong.
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