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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54

u/Extension-Scar-5513 Apr 29 '25

As others said, it's not illegal. But it would be a breach of their contract with your insurer. They could face penalties or even be removed from your insurance company's network if they don't submit claims.

Another comment said to lie and pay cash price for your procedures then submit to insurance yourself. Do not do that. The insurance company will see that it's an in network provider and will then force the provider to submit the claim.

11

u/guri256 Apr 29 '25

Are you sure? You are correct if the insurance company is private, but if OP has insurance through Medicare or Medicaid, I think it can literally be illegal.

7

u/OneLessDay517 Apr 29 '25

OP described private insurance, so why would anyone answer as if it were Medicaid?

1

u/pellakins33 Apr 29 '25

To be fair, someone reading the comments may have Medicare/Medicaid. If you don’t specifically call it out as an exception, you could be inadvertently giving them a misleading answer