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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35

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!

12

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/Superb-Grape7481 May 02 '25

They just misspelled hippo, give them a break, spelling Nazi 😃

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u/lady_goldberry May 01 '25

When people spell it incorrectly I don't even read the comment : )

9

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!

1

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

2

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.

1

u/Superb-Grape7481 May 02 '25

Drug interaction would be my guess

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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