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/RetiredBSN Apr 30 '25
Is that what the doctor is billing, or is that what’s left for you to pay after the insurance applies their discounts and pays their part? If it’s what’s being billed by the doctor, I’m pretty sure that’s not going to end up being what you pay. You should get an estimate of benefits (EOB) from your insurance showing 1) what the doctor is billing; 2) the amount the insurance considers reasonable and customary (and what they have contracted to pay the doctor); 3) the amount of the bill they paid; and 4) the portion of the bill that you owe. EOBs are sometimes
A doctor may bill whatever he wants, but insurance is going to limit that to the customary amount, and even if the insurance is not covering anything, your payout should not exceed what the insurance company allowed.