Illegal to not bill through insurance?

[u/MenuRare9880]

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.

[u/goopstastic]

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!

[u/Constant_Demand_1560 → u/goopstastic]

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?

[u/goopstastic → u/Constant_Demand_1560]

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!

[u/pellakins33 → u/Constant_Demand_1560]

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