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.
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.
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.
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!
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.
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!
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.
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?
I’m going to go to Mexico to get anonymous and affordable healthcare. I have a condition that was in remission for 16 years. If I show up to any doctor with this condition they will treat me like a piece of trash. It wasn’t that way before. I could get transported to the hospital and helped to get back on the road to recovery. The pandemic has made crooks out the healthcare system.
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.
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.
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.
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.
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.
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!
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.
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!
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.
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!
I’m going to go to Mexico to get anonymous and affordable healthcare. I have a condition that was in remission for 16 years. If I show up to any doctor with this condition they will treat me like a piece of trash. It wasn’t that way before. I could get transported to the hospital and helped to get back on the road to recovery. The pandemic has made crooks out the healthcare system.
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.