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.

86 Upvotes

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53

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.

10

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.

7

u/OneLessDay517 Apr 29 '25

OP described private insurance, so why would anyone answer as if it were Medicaid?

1

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

-2

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.

5

u/OneLessDay517 Apr 29 '25

But that is not what OP described!

3

u/goizn_mi Apr 29 '25

That's not at all what is being said, though?

2

u/MenuRare9880 Apr 29 '25

I have private insurance

1

u/Key_Employment4536 May 02 '25

It’s wrong, no matter who the insurance is

2

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?

1

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.

0

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.

1

u/Infamous_Try3063 Apr 29 '25

Healthcare provider checking in.  This is correct.

0

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.

1

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.