Hi Marshall - I came across this post while looking to a solution I am currently facing.
I have been experiencing a severe vestibular issue for almost 6 months now, and have been to multiple doctors (11 and counting) with no relief, nor even a solid diagnosis.
A large local university health system has a specialized vestibular clinic, and my GP referred me there to see if we could find a solution. It took several weeks for them to accept the referral, and I spoke to them yesterday about an appointment. The scheduling person said I wound need to speak with finance first, and transferred me.
Finance told me since my insurance is out of network (and aligned with another local university health system), they would not schedule me. I told them I'd like to cash pay, would be happy to put a card on file, and sign any required payment responsibility paperwork. She refused all of this, and said that if I had out of network insurance there was no way I could be seen in their system, and since I had insurance cash pay was not an option.
My GP practice called on my behalf - explained the ongoing problems I'm facing, and the fact that my network does not have a specialty practice in the area I need. They asked what else was needed to get the referral through as an exception, and was told the same thing I was and that this was a new policy they created in 2021. My doctors office questioned the legality of this and mentioned HIPAA, and they were told it was just the new policy.
This sounds similar, but not exactly the same as this post. Do you have any thoughts or suggestions on this? Thank you for helping us navigate this broken system!
This is such a tough situation, Ed, and I wish I had an easy solution for you. The truth is, if it's not emergency care, a clinic or doctor is not legally required to work with a patient. So if they refuse to change unreasonable policies then the patient is stuck - either accept the unfair policy or go somewhere else. But it's hard to go somewhere else if there's no one nearby that offers that type of care. Any other readers have a solution for this one?
Gap exception, get insurance to cover them at in network rates given the gravity of the situation. It’s a special type of prior auth but it can be done.
Interesting - I always thought self-pay charges were higher, not lower, than negotiated insurance rates! But... you do note that when you self-pay, that doesn't get you closer to your insurance deductible (e.g., a HDHP, which I have). So if this is the only health care you need this year, great, you save money. But if someone goes into the hospital next month, you get whacked for the whole deductible. So if your health-care costs are very low in a given year, sure, this will save you some money. But I'm not about to call HR and cancel my insurance!
Of course. If one does have a catastrophic event that would get patient past the OOPM, then just have the claims processed through insurance and get a refund for the difference,
Yeah, this is my issue with cancer treatment costs. Some people have said “just pay cash it’s always cheaper” without taking the long term impact into account. As if the incredibly expensive drug will drop to $100 and it will be fine...I pay less overall meeting my deductible and max out of pocket than I would cash. I wish I would have known this when I was in my early twenties and only did urgent care though!
I had an interesting experience with this in Oregon. My primary care provider's office decided to stop taking out-of-network insurance. I requested to pay as self-pay (I had previously had in-network coverage). They denied it, and I was not permitted to make an appointment. I called the Oregon State Consumer Advice Division for Health Insurance and was told that although it is my right to self-pay, the medical group has the right to a policy prohibiting insured patients from paying self-pay. Their comment was that although it may be unethical, it is not illegal for them to have this policy.
Thank you for your comment, Kate! Medical providers are only required by law to provide emergency care. So they may turn patients away for non-emergency care if the patient doesn't abide by their policies. That's a tough situation if you can't find a different provider that offers the same services!
Glad Pam stood up for herself! I have been in medical billing for 25 years and am Currently Director of RCM. Amy office/facility can have an Elect to Self Pay consent signed by the patient for services rendered.
We should always do what is best for our patients even financially.
Thank you for your comment, Holly! Yes, many medical providers are making self-pay an option. It's the ethical thing to do and get rid of the middleman, so the provider can be paid sooner. Glad to hear that's been your experience!
Hi Holly. I’m a coder and advocate for patients from time to time. I believe we have a fiduciary duty to the patient to maximize benefits as appropriate, bill appropriately, and collect appropriately. Like billing 94002 and 94003 for 13 hours (overnight) of vent time is ridiculous. Modifier 25 and 59, not using preventative codes when required (surgical sterilization for example) are areas we still need to focus on as an industry.
Interesting post Marshall. A couple of things that I've noted that are an additional wrinkle in situations such as Pam's. For most hospitals, cash prices may not be lower than insurance reimbursement rates. I believe this has been evidenced with the price transparency data as well - cash prices tend to be in the median range of reimbursement rates. In the case of my hospital the cash prices are much higher than insurance rates (e.g., MRI - $6500 cash; $5500 with HDHP. (I get mine for $300 cash at an independent, but that's another story.) Additionally, in some states even university hospitals will not allow cash if the patient is insured. They are obligated to check even if the patient does not disclose their insurance status. In other states, hospitals have told me to 'lie' about not having insurance, because if you tell them, they have to bill insurance. This is per the contracts they have with the carriers, and seems to have statewide implications far as I've checked. I am curious whether the HIPAA clause you have identified overrides these contractual clauses. It does not read to me that the HIPAA language gives the patient absolute right to bypass insurance unless the provider agrees - rather it is a clause for information disclosure to the carrier.
Thank you for your comment, Sam. HIPAA is federal law and would trump contracts, I think, but you never know until you try. One thing I do know is how paranoid health care providers are about violating HIPAA. So I think that could be helpful for patients who want to pay cash. Also, if they say their contracts REQUIRE using insurance, and insurance costs more than cash, then my recommendation would be to sue them in small claims court for the difference. Hospitals/providers and insurers don't just get to price gouge patients and then have the patients say, "Oh, OK, here's my money." I include a chapter in my book about small claims court and have found it to be quite effective.
Thank you for clarifying, Marshall. As I understand it, HIPAA is about patient privacy only. A provider not willing to accept cash because of their carrier contract would not violate HIPAA. Going to court is a last resort and most patients don't have the stomach for that unless there is a lot of $ in question, IMO.
HIPAA is about MUCH more than just patient privacy. It also is about giving patients CONTROL of their Private Health Information, and ACCESS to their PHI. If the patient tells the provider they do not have permission to share their PHI with an insurer, and the provider does so, then yes, that violates HIPAA, according to the OCR document I cited in this column. I come at this from the point of view of the patient, and from that perspective it’s unfair and unacceptable for insurers and providers to create contracts that force patients to pay more than they should and/or allow for violating their patient privacy rights. So, as you can see, I am not persuaded by the “we have a contract” argument.
Noo. As a Health Information Professioanl, I can tell you that HIPAA covers way more. It covers the code sets that are used, how they are used, how providers are paid (in the administrative section). There are rules on privacy, security, integrity of the medical record…so much more.
My question is if I present my orthopedic office with this health information, privacy, right brochure , so that I can self pay for my physical therapy, if down the road I need to have surgery ,am I able to then have my insurance billed for the surgery and anything going forward. I have a $5000 deductible and I don’t anticipate meeting that deductible this calendar year since they feel my issue can be resolved With physical therapy.
Hi Leslie, thank you for your question. You can just give permission to bill your insurance, or remove permission, at your discretion. It's your right to say whether they can or can't, and you're free to change your mind. They are also free to turn you away as a patient if it's not an emergency and they do not agree with your terms. So it's an ongoing conversation with them. They want your business, so they should be willing to work with you on it.
OK, thank you for the information. However, this scenario has gone in the wrong direction now, when I started in this office, they allowed me to self pay for my MRI and at that point, I assumed that I was a self-pay patient. I was given a quote for a self-pay cortisone injection then Had that injection, and then came to find out that they billed my insurance for the office visit and the injection. I was still and am still in a lot of pain and I need physical therapy. When I told the office I was wanting to start physical therapy, they quoted me a self-pay price and they also let me know that if they build insurance it would be a lot more than that. The day before my physical therapy was to start the office called me and told me that they had to bill the insurance for the physical therapy, and that there was no way, because they are contracted with medical mutual that they can allow me to be a self-pay patient because of that contract. I then came across your article and went into the office today with my little bit of ammunition. I was stopped by the billing department manager almost immediately and told that due to the contract, they cannot allow me to be self-pay, I quoted the civil rights and Hyppa information, showed her the brochure and told her that I knew my rights, and that my insurance company told me there should be a waiver I can sign so that I can be a self-pay patient. She told me I needed to call there offsite mother billing department ortho alliance. I called ortho alliance and at first I thought I was getting somewhere, but then they just called me back and stated that the office is correct and that I cannot be a self-pay patient because they are contracted with medical mutual. As a matter of fact, they also told me that they can see that I self paid my MRI, and that they are going to go back and bill that to the insurance. I made it very clear that I wouldn’t be paying any more on the MRI even if I was sent a bill since this was not my mistake, the office allowed me to be self pay. Now I feel like I am stuck, I feel like I have a red flag next to my name , and I’m not sure what to do. I have called two other orthopedic offices, and because they’re affiliated with local hospital systems, My information for my insurance automatically pops up with my name ansd birthdate. They also to have told me that I cannot be a self-pay patient because they’re contracted with medical mutual. it is absolutely insane that I am being forced to pay triple or quadruple the amount that a self-pay patient would pay for services just because I have insurance that by the way, I pay a large premium for each month.
The article is misleading. Wrong, in fact. That’s not harsh. The article excellently highlights the difficulty in determining a correct answer. It’s just that the answer is far more nuanced than supported here, and this may give overconfidence to the reader. I agree that all patients need the information within this article, and should ask about cash pay vs billing their carrier. Just do not expect success to the degree that this article asserts. The title would be better as You May Be Able to Pay Cash… Here’s why.
The article says there’s no guarantee this will work. That is true – there is no absolute. But the article does not examine the second condition highlighted from the brochure from the federal Office for Civil Rights’ (OCR) HIPPA brochure, which is what I think gives the reader too much confidence. I think readers are left feeling that if they can pay then they can always be self-pay. That’s wrong.
The comments go so far as to state that HIPAA law beats contracts (contracts being a likely reason providers say they must bill the carrier). HIPAA does not beat all contracts. Period. I know, but hear me out because the proof of this is in the article; in that brochure. I mean, why else would there be the following conditions?
The first part of the highlighted sentence sounds solid: “Finally you can also ask your health care provider or pharmacy not to tell your health insurance company about care you receive or drugs you take.” But, there’s nothing about providers needing to comply. It does not say “…and providers need to comply. It’s the law.” That is because there are conditions that HIPAA allows, such as: “[if] the provider or pharmacy does not need to get paid by your insurance company.” I do not see that condition examined here.
To me that’s an odd phrase. To me, it is a phrase that makes less and less sense the more I re-read it. That is, until I read between the lines. It's legal-speak. But it's there: “[if] the provider or pharmacy does not need to get paid by your insurance company.”
What? Why is it there? What does this loophole mean? And most importantly, why isn’t it examined in this article?
I’m not going to put down my research on this – too long. But I will say this: Medicare – that and that HIPAA needed to leave an opening for the unknown. So, what is the unknown, and why would I say “Medicare”? As I said, nuanced answer. And one I’m not even sure about. But
Clearly I’d like to see this article revised. I came here as part of my research, and I think the author is amazing. And the source, Shelley Safian, should re-examine her assertion that “then the medical provider is forbidden from submitting the information to the insurance company,” because clearly that contradicts / ignores the second condition of the very thing this article cites.
Hi Eric - that's just the point: If the provider is paid cash then they do not need to be paid by your insurance company. As you said, there is nuance here, and it won't always work. And ultimately, if providers want to unreasonably make patients pay more by forcing them to use insurance, then the patient may want to find a different provider.
I just moved from Washington State, where I've had no problem with both great insurance and cash payment options, to California. Where no one will take you on as a patient without insurance! Everyone refuses cash. Thank you SO MUCH for this information. As soon as I started to push back with your information, I've had some success. No appointments yet. But hopefully?
Thanks and good for Pam! I have been considering doing the same and the HIPAA information is really helpful! I paid cash for a procedure recently but the place filed a claim with the insurance anyway. They they didn't inform me that my refund was available and it is all a mess. I finally got the refund but the whole thing was ridiculous. The difference is that I had already reached my deductible, so the refund was worth fighting for.
That does sound like a mess, Adriana! Nice work advocating for yourself. It is a hassle but I like to look at the money saved as the payoff for the time spent dealing with the hassle. We can save a lot of money by being engaged and advocating for ourselves.
Eye-opening! Thank you! But what if your provider or pharmacy says, as the second half of that statement in the HIPPA brochure does, that they "need to get paid by the insurance company"? I can imagine that happening.
Great question, Leanne! There is no guarantee that it will work to cite HIPAA. But it's a point of leverage that could be effective, and sway the discussion in favor of the patient. I also think it would give the patient leverage on the back end, if the medical provider bullies the patient into paying more by using insurance.
I work for a small group practice (MH/OT for young children). We don't want finances to be a barrier so we allow families to choose a rate (up to the full rate) for any visits that we can't bill directly to their insurance (currently there are OT sessions that don't meet code requirements). However, if a family requests not to use insurance at all, then we believe we need to charge either the rate submitted to insurance, or the allowed rate that their insurance will pay us (less than the cash rate) since we are in-network. We also state that if not using insurance, the family can't submit their own claim to insurance for reimbursement. My question is this: when a family doesn't want to use insurance, are we allowed to offer them a reduced rate from our stated visit fee, or less than their insurance allowed rate? Or do we need to be consistent with a cash pay rate for every family, even if it is higher than what insurance would pay us?
I work for a small group practice (MH/OT for young children). We don't want finances to be a barrier so we allow families to choose a rate (up to the full rate) for any visits that we can't bill directly to their insurance (currently there are OT sessions that don't meet code requirements). However, if a family requests not to use insurance at all, then we believe we need to charge either the rate submitted to insurance, or the allowed rate that their insurance will pay us (less than the cash rate) since we are in-network. We also state that if not using insurance, the family can't submit their own claim to insurance for reimbursement. My question is this: when a family doesn't want to use insurance, are we allowed to offer them a reduced rate from our stated visit fee, or less than their insurance allowed rate? Or do we need to be consistent with a cash pay rate for every family, even if it is higher than what insurance would pay us?
I found this out with medication; the pharmacies automatically (and insistently) want to use my high-deductible pays-for-almost-nothing health insurance, which jacks up the price of medicine more than triple in most cases. But I have had luck getting the manager/pharmacist to override that and let me pay "out of pocket" with a coupon instead. I also had an MRI of my back, and the radiology dept insisted that my "copay" was the entire annual deductible on my insurance -- which of course was a lot more than the MRI. I had to pay it up front that time, but got a reimbursement after I complained, although it took almost a year to get to me.
It is easy to explain why cash pay prices are cheaper than insurance prices. When someone pays me cash, I am immediately paid and done. When I have to bill insurance I sometimes don't see my payment for months, often get denied, have to write an appeal, etc. I have to have 2 employees just to deal with insurance companies, and their salaries and the cost of not having my money for 30 or more days has to be baked into the price for insured patients. However, I'm happy for anyone to pay my cheaper cash pay rates, and many patients with high-deductible plans do. The only issue with this is that everything they pay me isn't counted towards their deductible, but that's not my decision if it's worth it or not.
Hi Marshall - I came across this post while looking to a solution I am currently facing.
I have been experiencing a severe vestibular issue for almost 6 months now, and have been to multiple doctors (11 and counting) with no relief, nor even a solid diagnosis.
A large local university health system has a specialized vestibular clinic, and my GP referred me there to see if we could find a solution. It took several weeks for them to accept the referral, and I spoke to them yesterday about an appointment. The scheduling person said I wound need to speak with finance first, and transferred me.
Finance told me since my insurance is out of network (and aligned with another local university health system), they would not schedule me. I told them I'd like to cash pay, would be happy to put a card on file, and sign any required payment responsibility paperwork. She refused all of this, and said that if I had out of network insurance there was no way I could be seen in their system, and since I had insurance cash pay was not an option.
My GP practice called on my behalf - explained the ongoing problems I'm facing, and the fact that my network does not have a specialty practice in the area I need. They asked what else was needed to get the referral through as an exception, and was told the same thing I was and that this was a new policy they created in 2021. My doctors office questioned the legality of this and mentioned HIPAA, and they were told it was just the new policy.
This sounds similar, but not exactly the same as this post. Do you have any thoughts or suggestions on this? Thank you for helping us navigate this broken system!
This is such a tough situation, Ed, and I wish I had an easy solution for you. The truth is, if it's not emergency care, a clinic or doctor is not legally required to work with a patient. So if they refuse to change unreasonable policies then the patient is stuck - either accept the unfair policy or go somewhere else. But it's hard to go somewhere else if there's no one nearby that offers that type of care. Any other readers have a solution for this one?
Gap exception, get insurance to cover them at in network rates given the gravity of the situation. It’s a special type of prior auth but it can be done.
Ed-- sounds like a horrible situation. Would you be open to chatting? We think we have a solution here. Shoot me a message: ceo[at]estonmd.com
Interesting - I always thought self-pay charges were higher, not lower, than negotiated insurance rates! But... you do note that when you self-pay, that doesn't get you closer to your insurance deductible (e.g., a HDHP, which I have). So if this is the only health care you need this year, great, you save money. But if someone goes into the hospital next month, you get whacked for the whole deductible. So if your health-care costs are very low in a given year, sure, this will save you some money. But I'm not about to call HR and cancel my insurance!
No one is saying to cancel your insurance, John. Just check the cash prices and push to pay them if it makes sense for you.
Of course. If one does have a catastrophic event that would get patient past the OOPM, then just have the claims processed through insurance and get a refund for the difference,
Yeah, this is my issue with cancer treatment costs. Some people have said “just pay cash it’s always cheaper” without taking the long term impact into account. As if the incredibly expensive drug will drop to $100 and it will be fine...I pay less overall meeting my deductible and max out of pocket than I would cash. I wish I would have known this when I was in my early twenties and only did urgent care though!
I had an interesting experience with this in Oregon. My primary care provider's office decided to stop taking out-of-network insurance. I requested to pay as self-pay (I had previously had in-network coverage). They denied it, and I was not permitted to make an appointment. I called the Oregon State Consumer Advice Division for Health Insurance and was told that although it is my right to self-pay, the medical group has the right to a policy prohibiting insured patients from paying self-pay. Their comment was that although it may be unethical, it is not illegal for them to have this policy.
Thank you for your comment, Kate! Medical providers are only required by law to provide emergency care. So they may turn patients away for non-emergency care if the patient doesn't abide by their policies. That's a tough situation if you can't find a different provider that offers the same services!
Glad Pam stood up for herself! I have been in medical billing for 25 years and am Currently Director of RCM. Amy office/facility can have an Elect to Self Pay consent signed by the patient for services rendered.
We should always do what is best for our patients even financially.
Thank you for your comment, Holly! Yes, many medical providers are making self-pay an option. It's the ethical thing to do and get rid of the middleman, so the provider can be paid sooner. Glad to hear that's been your experience!
Hi Holly. I’m a coder and advocate for patients from time to time. I believe we have a fiduciary duty to the patient to maximize benefits as appropriate, bill appropriately, and collect appropriately. Like billing 94002 and 94003 for 13 hours (overnight) of vent time is ridiculous. Modifier 25 and 59, not using preventative codes when required (surgical sterilization for example) are areas we still need to focus on as an industry.
Interesting post Marshall. A couple of things that I've noted that are an additional wrinkle in situations such as Pam's. For most hospitals, cash prices may not be lower than insurance reimbursement rates. I believe this has been evidenced with the price transparency data as well - cash prices tend to be in the median range of reimbursement rates. In the case of my hospital the cash prices are much higher than insurance rates (e.g., MRI - $6500 cash; $5500 with HDHP. (I get mine for $300 cash at an independent, but that's another story.) Additionally, in some states even university hospitals will not allow cash if the patient is insured. They are obligated to check even if the patient does not disclose their insurance status. In other states, hospitals have told me to 'lie' about not having insurance, because if you tell them, they have to bill insurance. This is per the contracts they have with the carriers, and seems to have statewide implications far as I've checked. I am curious whether the HIPAA clause you have identified overrides these contractual clauses. It does not read to me that the HIPAA language gives the patient absolute right to bypass insurance unless the provider agrees - rather it is a clause for information disclosure to the carrier.
Thank you for your comment, Sam. HIPAA is federal law and would trump contracts, I think, but you never know until you try. One thing I do know is how paranoid health care providers are about violating HIPAA. So I think that could be helpful for patients who want to pay cash. Also, if they say their contracts REQUIRE using insurance, and insurance costs more than cash, then my recommendation would be to sue them in small claims court for the difference. Hospitals/providers and insurers don't just get to price gouge patients and then have the patients say, "Oh, OK, here's my money." I include a chapter in my book about small claims court and have found it to be quite effective.
Thank you for clarifying, Marshall. As I understand it, HIPAA is about patient privacy only. A provider not willing to accept cash because of their carrier contract would not violate HIPAA. Going to court is a last resort and most patients don't have the stomach for that unless there is a lot of $ in question, IMO.
HIPAA is about MUCH more than just patient privacy. It also is about giving patients CONTROL of their Private Health Information, and ACCESS to their PHI. If the patient tells the provider they do not have permission to share their PHI with an insurer, and the provider does so, then yes, that violates HIPAA, according to the OCR document I cited in this column. I come at this from the point of view of the patient, and from that perspective it’s unfair and unacceptable for insurers and providers to create contracts that force patients to pay more than they should and/or allow for violating their patient privacy rights. So, as you can see, I am not persuaded by the “we have a contract” argument.
Noo. As a Health Information Professioanl, I can tell you that HIPAA covers way more. It covers the code sets that are used, how they are used, how providers are paid (in the administrative section). There are rules on privacy, security, integrity of the medical record…so much more.
This was my experience - they basically told me I would have to lie to pay cash.
My question is if I present my orthopedic office with this health information, privacy, right brochure , so that I can self pay for my physical therapy, if down the road I need to have surgery ,am I able to then have my insurance billed for the surgery and anything going forward. I have a $5000 deductible and I don’t anticipate meeting that deductible this calendar year since they feel my issue can be resolved With physical therapy.
Hi Leslie, thank you for your question. You can just give permission to bill your insurance, or remove permission, at your discretion. It's your right to say whether they can or can't, and you're free to change your mind. They are also free to turn you away as a patient if it's not an emergency and they do not agree with your terms. So it's an ongoing conversation with them. They want your business, so they should be willing to work with you on it.
Please see post from March 7. Any advice is helpful.
OK, thank you for the information. However, this scenario has gone in the wrong direction now, when I started in this office, they allowed me to self pay for my MRI and at that point, I assumed that I was a self-pay patient. I was given a quote for a self-pay cortisone injection then Had that injection, and then came to find out that they billed my insurance for the office visit and the injection. I was still and am still in a lot of pain and I need physical therapy. When I told the office I was wanting to start physical therapy, they quoted me a self-pay price and they also let me know that if they build insurance it would be a lot more than that. The day before my physical therapy was to start the office called me and told me that they had to bill the insurance for the physical therapy, and that there was no way, because they are contracted with medical mutual that they can allow me to be a self-pay patient because of that contract. I then came across your article and went into the office today with my little bit of ammunition. I was stopped by the billing department manager almost immediately and told that due to the contract, they cannot allow me to be self-pay, I quoted the civil rights and Hyppa information, showed her the brochure and told her that I knew my rights, and that my insurance company told me there should be a waiver I can sign so that I can be a self-pay patient. She told me I needed to call there offsite mother billing department ortho alliance. I called ortho alliance and at first I thought I was getting somewhere, but then they just called me back and stated that the office is correct and that I cannot be a self-pay patient because they are contracted with medical mutual. As a matter of fact, they also told me that they can see that I self paid my MRI, and that they are going to go back and bill that to the insurance. I made it very clear that I wouldn’t be paying any more on the MRI even if I was sent a bill since this was not my mistake, the office allowed me to be self pay. Now I feel like I am stuck, I feel like I have a red flag next to my name , and I’m not sure what to do. I have called two other orthopedic offices, and because they’re affiliated with local hospital systems, My information for my insurance automatically pops up with my name ansd birthdate. They also to have told me that I cannot be a self-pay patient because they’re contracted with medical mutual. it is absolutely insane that I am being forced to pay triple or quadruple the amount that a self-pay patient would pay for services just because I have insurance that by the way, I pay a large premium for each month.
HELP! .
This is fantastic. Thank you!!!!!!!!!!
It is going to help me with a current self-pay battle with Hunterdon Healthcare in NJ.
It's not the first time we are getting over billed / wrongly billed by them.
They are mis-billing the line item. They are fibbing I can't self pay, when I requested self pay at check in.
They have stalled getting me an itemized bill.
Their local billing department is now not returning my calls.
I'm so glad to hear you're fighting this. Let me know how it worked out!
The article is misleading. Wrong, in fact. That’s not harsh. The article excellently highlights the difficulty in determining a correct answer. It’s just that the answer is far more nuanced than supported here, and this may give overconfidence to the reader. I agree that all patients need the information within this article, and should ask about cash pay vs billing their carrier. Just do not expect success to the degree that this article asserts. The title would be better as You May Be Able to Pay Cash… Here’s why.
The article says there’s no guarantee this will work. That is true – there is no absolute. But the article does not examine the second condition highlighted from the brochure from the federal Office for Civil Rights’ (OCR) HIPPA brochure, which is what I think gives the reader too much confidence. I think readers are left feeling that if they can pay then they can always be self-pay. That’s wrong.
The comments go so far as to state that HIPAA law beats contracts (contracts being a likely reason providers say they must bill the carrier). HIPAA does not beat all contracts. Period. I know, but hear me out because the proof of this is in the article; in that brochure. I mean, why else would there be the following conditions?
The first part of the highlighted sentence sounds solid: “Finally you can also ask your health care provider or pharmacy not to tell your health insurance company about care you receive or drugs you take.” But, there’s nothing about providers needing to comply. It does not say “…and providers need to comply. It’s the law.” That is because there are conditions that HIPAA allows, such as: “[if] the provider or pharmacy does not need to get paid by your insurance company.” I do not see that condition examined here.
To me that’s an odd phrase. To me, it is a phrase that makes less and less sense the more I re-read it. That is, until I read between the lines. It's legal-speak. But it's there: “[if] the provider or pharmacy does not need to get paid by your insurance company.”
What? Why is it there? What does this loophole mean? And most importantly, why isn’t it examined in this article?
I’m not going to put down my research on this – too long. But I will say this: Medicare – that and that HIPAA needed to leave an opening for the unknown. So, what is the unknown, and why would I say “Medicare”? As I said, nuanced answer. And one I’m not even sure about. But
Clearly I’d like to see this article revised. I came here as part of my research, and I think the author is amazing. And the source, Shelley Safian, should re-examine her assertion that “then the medical provider is forbidden from submitting the information to the insurance company,” because clearly that contradicts / ignores the second condition of the very thing this article cites.
I very much look forward to an update.
Hi Eric - that's just the point: If the provider is paid cash then they do not need to be paid by your insurance company. As you said, there is nuance here, and it won't always work. And ultimately, if providers want to unreasonably make patients pay more by forcing them to use insurance, then the patient may want to find a different provider.
I just moved from Washington State, where I've had no problem with both great insurance and cash payment options, to California. Where no one will take you on as a patient without insurance! Everyone refuses cash. Thank you SO MUCH for this information. As soon as I started to push back with your information, I've had some success. No appointments yet. But hopefully?
Thank you for all your hard work!
Thanks and good for Pam! I have been considering doing the same and the HIPAA information is really helpful! I paid cash for a procedure recently but the place filed a claim with the insurance anyway. They they didn't inform me that my refund was available and it is all a mess. I finally got the refund but the whole thing was ridiculous. The difference is that I had already reached my deductible, so the refund was worth fighting for.
That does sound like a mess, Adriana! Nice work advocating for yourself. It is a hassle but I like to look at the money saved as the payoff for the time spent dealing with the hassle. We can save a lot of money by being engaged and advocating for ourselves.
Eye-opening! Thank you! But what if your provider or pharmacy says, as the second half of that statement in the HIPPA brochure does, that they "need to get paid by the insurance company"? I can imagine that happening.
Great question, Leanne! There is no guarantee that it will work to cite HIPAA. But it's a point of leverage that could be effective, and sway the discussion in favor of the patient. I also think it would give the patient leverage on the back end, if the medical provider bullies the patient into paying more by using insurance.
I work for a small group practice (MH/OT for young children). We don't want finances to be a barrier so we allow families to choose a rate (up to the full rate) for any visits that we can't bill directly to their insurance (currently there are OT sessions that don't meet code requirements). However, if a family requests not to use insurance at all, then we believe we need to charge either the rate submitted to insurance, or the allowed rate that their insurance will pay us (less than the cash rate) since we are in-network. We also state that if not using insurance, the family can't submit their own claim to insurance for reimbursement. My question is this: when a family doesn't want to use insurance, are we allowed to offer them a reduced rate from our stated visit fee, or less than their insurance allowed rate? Or do we need to be consistent with a cash pay rate for every family, even if it is higher than what insurance would pay us?
I work for a small group practice (MH/OT for young children). We don't want finances to be a barrier so we allow families to choose a rate (up to the full rate) for any visits that we can't bill directly to their insurance (currently there are OT sessions that don't meet code requirements). However, if a family requests not to use insurance at all, then we believe we need to charge either the rate submitted to insurance, or the allowed rate that their insurance will pay us (less than the cash rate) since we are in-network. We also state that if not using insurance, the family can't submit their own claim to insurance for reimbursement. My question is this: when a family doesn't want to use insurance, are we allowed to offer them a reduced rate from our stated visit fee, or less than their insurance allowed rate? Or do we need to be consistent with a cash pay rate for every family, even if it is higher than what insurance would pay us?
I found this out with medication; the pharmacies automatically (and insistently) want to use my high-deductible pays-for-almost-nothing health insurance, which jacks up the price of medicine more than triple in most cases. But I have had luck getting the manager/pharmacist to override that and let me pay "out of pocket" with a coupon instead. I also had an MRI of my back, and the radiology dept insisted that my "copay" was the entire annual deductible on my insurance -- which of course was a lot more than the MRI. I had to pay it up front that time, but got a reimbursement after I complained, although it took almost a year to get to me.
Superb. H. Robert Silverstein, MD, FACC
It is easy to explain why cash pay prices are cheaper than insurance prices. When someone pays me cash, I am immediately paid and done. When I have to bill insurance I sometimes don't see my payment for months, often get denied, have to write an appeal, etc. I have to have 2 employees just to deal with insurance companies, and their salaries and the cost of not having my money for 30 or more days has to be baked into the price for insured patients. However, I'm happy for anyone to pay my cheaper cash pay rates, and many patients with high-deductible plans do. The only issue with this is that everything they pay me isn't counted towards their deductible, but that's not my decision if it's worth it or not.