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/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/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.