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/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/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.