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/Waste-Text-7625 Apr 29 '25

So is the $520 what you owe AFTER the bill was reduced to the insurance companies' contracted rate? Most of those rates are lower than what cash would be. Or was the $520 what you saw submitted to your insurance company? If so, wait until you get your EOB showing what the patient responsibility is. The doctors office can only bill the contracted rate and can not balance bill you for the remainder. So even though insurance won't pick up the tab, it usually works in your favor as you pay what their contracted rate is, which is usually very favorable.

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u/lemonlegs2 Apr 29 '25

Most cash pay rates are about ten percent of what negotiated rates are.

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u/Waste-Text-7625 Apr 29 '25

Your math doesn't compute in this case. Furthermore, i have never found a doctor (for regular visits) who charge less than insurance rates (especially mental health providers). Maybe you are just lucky in the area where you live or are talking about negotiating with hospitals for procedures, which may be way different than an ongoing charge that the OP is discussing in a non-hospital setting.

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u/lemonlegs2 Apr 29 '25

Nope. Why would you say math doesnt compute? I'm in an industry with bad health insurance. Ive never in my life had a bill be lower with insurance - perhaps the hospital birth of my child, burritos I wouldn't be surprised if that's cheaper cash as well. Everyone I know uses cash pay rates unless they are intending on having a large medical year. I think in 2025 it's more common across the board for cash to be lower and good insurance is the anomaly. Just a plain old thyroid lab for example, without insurance I can get for 25 dollars. With insurance it's 80. Had a baby 2 years ago labs with insurance- 2200, cash pay 350. Ultrasounds with insurance - 900, cash pay 150. On and on. When I was seeing physicians more regularly itd be around 300 after insurance, or 125 cash pay. My OB charges 2.5k without insurance, 7.5k with. My negotiated rate was like 6k. Ive seen a plain old therapist. 125 after insurance, 100 cash pay - true, smallest difference for that service.

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u/Waste-Text-7625 Apr 29 '25

So all my labs are much cheaper than Quest cash rates. They aren't even close. Doctor would be 50 percent more with cash. There is no way YOUR purchasing power is better than most networks. If you shirk in premiums and buy crap insurance, well, you get what you pay for. That is why sometimes going with a low premium is not a good deal for those who actually will use their insurance, even with a higher deductible.

But again? Just because you had a certain experience doesn't mean yout bullshit made up statistics like 10 percent cash costs is ethical or appropriate to post.

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u/lemonlegs2 Apr 29 '25

Again, I have talked to many people, in many different locations, across several networks. It is normal for cash pay rates to be cheaper. The problem is medical charges reasonable rates for cash, then a huge markup to insurance to ensure they don't miss out on any dollars. For example, my lab that was 350 cash or 2200 after insurance. They initial bill to insurance was 10k. They would never quote that to a cash pay patient.

I don't understand why this sub loves health insurance and thinks anyone with a bad experience is a moron. I guess everyone here works in insurance?

We pay 550 a month in premiums for the best plan we have access to through UHC, previously BCBS. My company's policy, which I don't have anymore, is 1100 a month in premiums. And has been quoted by a provider as "the worst insurance they've ever seen". High premium does not automatically equal good negotiated rates and coverage.

It's great you have great insurance, but that's not the norm.