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/Sad-Contract9994 → u/goopstastic]

You seem to know a lot! This is completely off-topic but I’ve always wondered and maybe you have random knowledge. Why is it that Rx data is exempt from HIPAA such that private companies are able to buy this data and that doctors are able to buy into a service that provides it? I am even surprised when one entirely unrelated provider has access to a database of Rx for a patient that is not part of a controlled substances or tracking program (like scheduled meds, Accutane, pseuphedrine, etc)

This came back to my mind with the news that HHS is considering using commercially available data on Rx to help its catalog of those diagnosed with Autism (the implications of which I am not including here bc I don’t wanna make a stir..: but I think it’s obvious how I feel about that.)

[u/goopstastic → u/Sad-Contract9994]

well now you've sparked a new area of interest for me! pharmaceutical, dental, vision, and medical benefits are all subject to different requirements under hipaa. my best guess without any prior research would be that there is a loophole in pharmaceutical benefits that are not subject to the privacy rule under hipaa. unfortunately, pharmaceutical companies and representatives are ruthless and are only in it to make an extra buck. we actually had to ban pharmaceutical representatives from coming into the office to do anything except leave information.

as far as RFK's autism registry he'd like to create, it would be a violation under hipaa since it is a medical diagnosis unless the patient volunteered to share this information with the state/federal governments. this is the issue he will run into to mandate the registry. my best guess is that he wants to pull from the RX catalog since it is not subject to the same regulations, but i don't know how he would realistically be able to bypass hipaa with even that loophole.

[u/Superb-Grape7481 → u/goopstastic]

Drug interaction would be my guess