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/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/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/positivelycat Apr 29 '25

Okay but this comment was under the thread where I explained its not illegal but all the other things. I thought this thread moved on from illegal. You commented on a comment not

This thread moved on from illegal to other concerns and consequences.

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u/LuluGarou11 Apr 29 '25

Lol change the goalposts much…

Perhaps you didn’t mean to reply to me to begin with? 

If you did in fact mean to reply to me and derail this comment thread: Maybe try policing someone else. You literally inserted yourself into comments discussing legality on this one. 

Many misconceptions about legality here (not to mention many assuming Medicaid patients have less rights than anyone else). 

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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.