health insurance--must use the policy if youve got it?

[iris lily]

I am curious to know if anyone has an authoritative answer about how health insurance works in this theoretical case: choosing to pay out of pocket when I am coverd by an insurance  policy.

Heres my question: is it even an option that I pay for treatment out of pocket? I suspect it is not. i suspect the insurance company is obligated by law to pay out, but I would like confirmatin.

I'm  not interested in opinions about why paying myself is a bad dea.

[ZiziPB]

You always have the right to pay yourself, whether it's health insurance or any other insurance.  Unless you make a claim under your insurance policy, there is no obligation on the part of insurance company to pay.

[rubybeth]

In the US, you are definitely allowed to not have something billed to your medical insurance. Just tell your medical provider to send you a bill and not submit to your insurance. Some places might give you a discount for paying directly, for example, my husband's chiropractor offers a discount if you don't use insurance (it saves them lots of billing time and hassle) so some of their patients don't bother using their insurance.

[bacchi]

If a provider takes XYZ insurance and you let them know that you have XYZ insurance, the provider is obligated to submit a claim.

You don't have to let them know, of course, but I have had providers refuse to treat me when I declined to give them my insurance card (even when waving a credit card in front of them). The best option is to tell them that you don't have insurance and want to self-pay at the time of service.

[Blonde Lawyer]

If you are trying to get a controlled substance outside of your insurance company's guidelines, your pharmacy may refuse to serve you.  As far as I can tell, that is legal. Example: doctor gives you three prescriptions.  One said fill after Oct. 1.  Second, fill after Nov. 1.  Third, fill after Dec. 1.  You didn't take it everyday so you did't fill the Nov. one until Nov. 15.  You used it more that month but never more than prescribed.  In Dec. you were going on vacation and wanted to fill it Dec. 5.  Insurance says you have to wait 28 days to fill a controlled substance again.  You have a valid prescription that by law could be refilled before 30 days.  It just violates your insurance contract.  So, you can pay cash instead of letting insurance pay.  The pharmacy could say that violates their policies and refuse to fill it for you outside of insurance.

[Rural]

If a provider takes XYZ insurance and you let them know that you have XYZ insurance, the provider is obligated to submit a claim.

This is not the case. It may have been confusion or fraud from a provider or even an unscrupulous clause in a contract between a provider and an insurance company, but it is not a legal or universal obligation.

[Jschange]

Where do you live? Is the medication/treatment covered by government insurance or private? In Canada, seeing a 'regular' doctor, but paying privately would be difficult and maybe impossible if you are covered by your provincial insurance. You'd want to book in with one of those private doctors I hear rumours about.

Getting a prescription filled or seeing an optometrist, services usually paid for by private insurance would be easy. You just say that you'll pay out of pocket. Even if your insurance is on file you can ask them not to run it.

[Elliot]

Yes, you can certainly choose to not bill your insurance.

-at one time, my insurer only covered 20 of a particular medication I was taking per month. I could choose to get 20 covered with my regular $10 co pay and then the next 10 pills I paid full price for, or I could choose to take a partial fill. What I ACTUALLY did was ask them to send the script to a different pharmacy which I knew charged much less per pill for the medication but did not accept my insurance. It was almost $5 cheaper to bypass my insurance company altogether.

-I get 24 chiropractor/physical therapy visits covered (with small copay) per year. After that, I have to pay full price. If I leave the insurance company out of it altogether for those "extra" visits, I can pay the practice's cash-pay price and get a 20% discount off of full price.


As pp have said, if you're trying to fudge the system with controlled substances, I encourage you to stop, look at your life choices, and don't. In a legal manner, you don't want that juju in your life. In an addictions/abuse manner, you also don't want that juju in your life.

[CATman]

You can pay out of pocket by refusing to provide your insurance information to the medical provider, but you may end up paying a higher rate. If a medical provider accepts your insurance, they most likely have a negotiated rate for services rendered and that means that instead of paying the "retail" rate for services your will actually pay the rate the insurance company has negotiated with the provider.

I used to work in medical claims so I would see bills from hospitals drop by 50% or more once the hospital found out the person had health insurance. It was not uncommon to see ER bills go from tens of thousands to a couple thousand due to negotiated rates.

I would question why you are trying to not have the claim reported to your health insurance though because it could only save you money. Not to mention that most people have a high deductible plan these days and not reporting a claim through your insurance means that those bills would not count towards your deductible/out of pocket maximum.

[iris lily]

Where do you live? Is the medication/treatment covered by government insurance or private?

In U.S.

[Jack]

If you are trying to get a controlled substance outside of your insurance company's guidelines, your pharmacy may refuse to serve you.  As far as I can tell, that is legal. Example: doctor gives you three prescriptions.  One said fill after Oct. 1.  Second, fill after Nov. 1.  Third, fill after Dec. 1.  You didn't take it everyday so you did't fill the Nov. one until Nov. 15.  You used it more that month but never more than prescribed.  In Dec. you were going on vacation and wanted to fill it Dec. 5.  Insurance says you have to wait 28 days to fill a controlled substance again.  You have a valid prescription that by law could be refilled before 30 days.  It just violates your insurance contract.  So, you can pay cash instead of letting insurance pay.  The pharmacy could say that violates their policies and refuse to fill it for you outside of insurance.

I don't think that necessarily has anything to do with insurance; I think that's just the pharmacy complying with the Controlled Substances Act.

(The insurance part would only come in because it's the insurance that knows there were three prescriptions -- if you filled at three different pharmacies and paid cash then each pharmacy might not realize it. Of course, with the advent of prescription drug monitoring programs -- which, by the way, I wrote software to implement at my previous job -- that loophole is closing.)

[Blonde Lawyer]

If you are trying to get a controlled substance outside of your insurance company's guidelines, your pharmacy may refuse to serve you.  As far as I can tell, that is legal. Example: doctor gives you three prescriptions.  One said fill after Oct. 1.  Second, fill after Nov. 1.  Third, fill after Dec. 1.  You didn't take it everyday so you did't fill the Nov. one until Nov. 15.  You used it more that month but never more than prescribed.  In Dec. you were going on vacation and wanted to fill it Dec. 5.  Insurance says you have to wait 28 days to fill a controlled substance again.  You have a valid prescription that by law could be refilled before 30 days.  It just violates your insurance contract.  So, you can pay cash instead of letting insurance pay.  The pharmacy could say that violates their policies and refuse to fill it for you outside of insurance.

I don't think that necessarily has anything to do with insurance; I think that's just the pharmacy complying with the Controlled Substances Act.

(The insurance part would only come in because it's the insurance that knows there were three prescriptions -- if you filled at three different pharmacies and paid cash then each pharmacy might not realize it. Of course, with the advent of prescription drug monitoring programs -- which, by the way, I wrote software to implement at my previous job -- that loophole is closing.)

Many times insurance companies have stricter guidelines than the law and many pharmacies won't circumvent that via cash pay.

On the issue regarding getting the contracted insurance rate, as part of the affordable care act, hospitals are required to charge self pay patients no more than the average or highest (don't remember which and I know there is a big difference) rate that they have contracted with insurers.  Many are still trying to charge the old rates but if you ask them whether this has been adjusted to match their usual and customary insured rates they will adjust.  Be careful if they just offer a "self insured discount."  That might just be 10 or 20% and not close to the amount they usually accept from the insurance companies.  They are supposed to be doing this on their own but they aren't and you need to ask it the right way to get it right.

Also, here is another good reason people may want to bypass insurance.  If you are on someone else's insurance, the person holding the policies gets all of the EOBs.  So, you may want to have treatment without your parents knowing if you are a 25 year old on mom's plan.  Or you might want treatment without your husband (or ex husband) knowing if you are on his plan.  How that doesn't violate HIPPA is beyond me.  The policy holder can't even ask that the EOB's go to the named patient instead.  My husband just hands them all over to me. 

[Midwest]

As far as I know it's legal.  I'm doing it right now as the cash discount combined with a HDHP made it a good bet unless health costs are really high this year.

[Rural]

My current physical therapy is $69 a visit cash pay or over $300 a visit charged to my insurance, so no need to have any nefarious motive. I'm hoping not to meet my deductible this year, so it's all out of pocket.

[Elliot]

As pp have said, if you're trying to fudge the system with controlled substances, I encourage you to stop, look at your life choices, and don't. In a legal manner, you don't want that juju in your life. In an addictions/abuse manner, you also don't want that juju in your life.

Haha! I think the only think Iris Lily is addicted to is her flowers, her bulldogs, and an occasional glass of Two Buck Chuck.

Addiction can happen to otherwise very lovely and well-adjusted people. Source: working in mental health and addictions field.


My cash pay for chiro/pt/massage is 55/visit but when they bill my insurance they charge them 150.

[iris lily]

As pp have said, if you're trying to fudge the system with controlled substances, I encourage you to stop, look at your life choices, and don't. In a legal manner, you don't want that juju in your life. In an addictions/abuse manner, you also don't want that juju in your life.

Haha! I think the only think Iris Lily is addicted to is her flowers, her bulldogs, and an occasional glass of Two Buck Chuck.

Addiction can happen to otherwise very lovely and well-adjusted people. Source: working in mental health and addictions field.

Then we for sure don't have to worry about Iris Lily ;-)! I'm just making jokes as the OP knows so just ignore me and I'll go off and sulk in a corner :)

Spartana is just yanking my chain, no problem!

[bacchi]

If a provider takes XYZ insurance and you let them know that you have XYZ insurance, the provider is obligated to submit a claim.

This is not the case. It may have been confusion or fraud from a provider or even an unscrupulous clause in a contract between a provider and an insurance company, but it is not a legal or universal obligation.

Correct, it's a contractual obligation between the provider and insurer.

[southern granny]

I worked at a medical clinic for a couple of years.  Every year we would have some people who wanted to pay for their flu shots instead of having them billed to Medicare.  I never understood why, because Medicare covered it at 100%. But I called Medicare to find out.  I was told that we had to bill it to Medicare, but they told me something to put on the billing form that would stop them from paying (I don't remember specifically what it was) and then we could bill the patient.  But the patients didn't want to do that either, so they would just go ahead and let us bill the Medicare.  Clinics have contracts with all those insurance companies that require that the insurance be billed.  So I think the only way to do it would be to not let them know you have insurance.   

[goatmom]

If you are a doctor that takes medicaid or medicare - you cannot let a pt self pay.  It is against the law.  Not sure if it is the same with other insurance companies but I suspect once the doctor signs the contract to be a participating provider - he/she needs to bill the insurance company.

Many people don't want the insurance company knowing their personal business. They prefer to pay cash.  If you are really wanting to self pay - just find a doctor that doesn't participate in your insurance. 

[Rural]

Again, I've done insurance first, then self pay, with the same provider, a couple of weeks apart. So this is not universal, and it's worth asking regardless of whether you've used insurance with that provider or not.


Have done the same with prescriptions, so also worth asking there.


 Perhaps not every state allows third parties to put such restrictions on people's interactions with their healthcare providers.

[Paul der Krake]

On the issue regarding getting the contracted insurance rate, as part of the affordable care act, hospitals are required to charge self pay patients no more than the average or highest (don't remember which and I know there is a big difference) rate that they have contracted with insurers.  Many are still trying to charge the old rates but if you ask them whether this has been adjusted to match their usual and customary insured rates they will adjust.  Be careful if they just offer a "self insured discount."  That might just be 10 or 20% and not close to the amount they usually accept from the insurance companies.  They are supposed to be doing this on their own but they aren't and you need to ask it the right way to get it right.

Wow, that's a very interesting nugget of knowledge right there! Do you (or anyone who knows how to look for statutes) have a link to an authoritative source on this? And is this just hospitals, or are other types of provider that this applies to?

[Blonde Lawyer]

On the issue regarding getting the contracted insurance rate, as part of the affordable care act, hospitals are required to charge self pay patients no more than the average or highest (don't remember which and I know there is a big difference) rate that they have contracted with insurers.  Many are still trying to charge the old rates but if you ask them whether this has been adjusted to match their usual and customary insured rates they will adjust.  Be careful if they just offer a "self insured discount."  That might just be 10 or 20% and not close to the amount they usually accept from the insurance companies.  They are supposed to be doing this on their own but they aren't and you need to ask it the right way to get it right.

Wow, that's a very interesting nugget of knowledge right there! Do you (or anyone who knows how to look for statutes) have a link to an authoritative source on this? And is this just hospitals, or are other types of provider that this applies to?

Here is a NH statute on the issue:
http://www.gencourt.state.nh.us/rsa/html/xi/151/151-12-b.htm

Cites section 9007 of the ACA.

[iris lily]

This has been an interesting discussion.

There used to be this idea passed around that uninsured people were always charged much higher than rates that had been negotiated by the insurance companies.  I am guessing, if that were true (and I heard it often enough to think there was some truth in it) that the ACA changed this situation.

[AlwaysLearningToSave]

In my experience, I have been able to pay cash at time of service to a healthcare provider to get a significant discount compared to the rate I would be charged if I had the care billed through insurance.  This works well for providers with a fixed per-visit fee, like dentists, chiropractors, physician office visits, etc.

My wife and daughter are on a privately-purchased HDHP, so I have a strong interest in negotiating the lowest possible rate.  We are young and healthy and chances are we will not satisfy the deductible.  I have wondered if it is possible to save receipts for services I paid without insurance and then submit them for reimbursement after the fact in the event of a significant injury or illness with big medical bills.  I called my health insurer to ask this question and the customer service representative told me that the provider must bill insurance for it to count toward the deductible, but I'm not 100% sure I believe the answer. 

Is anyone aware of any law that would require a health insurer to count medical expenses paid in cash at time of service toward satisfaction of the deductible?

[goatmom]

We only take cash where I work.  People often ask for superbills to file with their insurance to count towards their deductable.  Not exactly sure if it differs from one insurance company to another since we don't get involved in that part of it.

[CATman]

This has been an interesting discussion.

There used to be this idea passed around that uninsured people were always charged much higher than rates that had been negotiated by the insurance companies.  I am guessing, if that were true (and I heard it often enough to think there was some truth in it) that the ACA changed this situation.

It depends on the provider. As was stated in a previous post, lots of providers who charge a fixed fee for services will charge a lower "cash" rate for self paying patients as it saves them money in the long run. They don't have pay staff to fill out or follow up on claims forms. However, if you go to an ER, most hospitals will charge you a much higher rate as an uninsured person than the contractual rate they have with insurance providers. I handled medical claims for an insurer after the ACA was passed and I saw this practice all the time.

http://www.nytimes.com/2013/08/27/health/exploring-salines-secret-costs.html?_r=0

This article is a little off topic, but has a great section where it shows how the exact same bag of saline costs different amounts for different patients just because of the insurance or lack thereof.

[Blonde Lawyer]

This has been an interesting discussion.

There used to be this idea passed around that uninsured people were always charged much higher than rates that had been negotiated by the insurance companies.  I am guessing, if that were true (and I heard it often enough to think there was some truth in it) that the ACA changed this situation.

It depends on the provider. As was stated in a previous post, lots of providers who charge a fixed fee for services will charge a lower "cash" rate for self paying patients as it saves them money in the long run. They don't have pay staff to fill out or follow up on claims forms. However, if you go to an ER, most hospitals will charge you a much higher rate as an uninsured person than the contractual rate they have with insurance providers. I handled medical claims for an insurer after the ACA was passed and I saw this practice all the time.

http://www.nytimes.com/2013/08/27/health/exploring-salines-secret-costs.html?_r=0

This article is a little off topic, but has a great section where it shows how the exact same bag of saline costs different amounts for different patients just because of the insurance or lack thereof.

It's actually a little more complex than this.  Basically, let's say a doctor would charge $300 for an office visit.  Most people have BCBS insurance.  BCBS comes to the doc and says "hey doc, you aren't going to get any patients unless you agree to be in network with us.  But, we expect to get 35% off of your rate."  So, the good doc agrees and contracts to accept $200 total for seeing BCBS patients (likely $150 from the insurer and $50 from the patient) and continues charging everyone else $300.  BCBS requires the doctor to bill and receive the $50 copay from the patient because BCBS wants every patient to have skin in the game to make sure they only go for legitimate medical things (because those silly patients like to go to the doctor for fun.)

So some facilities wanted to make medical care more affordable for their self-pay patients and started charging less to uninsured patients and more to insured patients.  Some states decided this was insurance fraud.  Medicaid came along and said "well, you can charge self-pay whatever you want but we will only pay 70% (or whatever it was) of what you are charging your self-pay patients."  So, in order to continue to make money, the provider than jacks up the self-pay amount.

I'm not sure how Medicaid works post ACA since you can't have both - charging self-pay the same as the insured and charging Medicaid a percent below self-pay.  I'm guessing for those purposes, Medicaid isn't considered an insurance company but I'm not an expert.

[bacchi]

SEC. 9007. ADDITIONAL REQUIREMENTS FOR CHARITABLE HOSPITALS.

‘‘(5) LIMITATION ON CHARGES.—An organization meets the requirements of this paragraph if the organization—
‘‘(A) limits amounts charged for emergency or other medically necessary care provided to individuals eligible for assistance under the financial assistance policy described in paragraph (4)(A) to not more than the lowest amounts charged to individuals who have insurance covering such care, and
‘‘(B) prohibits the use of gross charges.

It only applies to non-profit hospitals and only if the individual is eligible for assistance.

[JRA64]

I think it pays to shop around and ask questions, especially if you don't meet the deductible. My chiropractor has to charge the negotiated rate if I go through insurance, but will sell a 6-pack of visits at a reduced cost if I self-pay. A few years ago (before ACA) I had a simple surgery to remove a small growth. I talked to the surgeon. She thought it was simple enough to do in her office, and I asked what it would cost through insurance and through self-pay. I'd be paying anyway since I didn't hit the deductible that year. It was over $800 to go through insurance and a third less to self-pay. It took several weeks to get the cost estimate - they weren't used to fielding these questions - but I wasn't in a hurry.

[AlwaysLearningToSave]

We only take cash where I work.  People often ask for superbills to file with their insurance to count towards their deductable.  Not exactly sure if it differs from one insurance company to another since we don't get involved in that part of it.

What type of healthcare provider do you work for? And what do you mean by "superbills?"

[rubybeth]

In my experience, I have been able to pay cash at time of service to a healthcare provider to get a significant discount compared to the rate I would be charged if I had the care billed through insurance.  This works well for providers with a fixed per-visit fee, like dentists, chiropractors, physician office visits, etc.

My wife and daughter are on a privately-purchased HDHP, so I have a strong interest in negotiating the lowest possible rate.  We are young and healthy and chances are we will not satisfy the deductible.  I have wondered if it is possible to save receipts for services I paid without insurance and then submit them for reimbursement after the fact in the event of a significant injury or illness with big medical bills.  I called my health insurer to ask this question and the customer service representative told me that the provider must bill insurance for it to count toward the deductible, but I'm not 100% sure I believe the answer. 

Is anyone aware of any law that would require a health insurer to count medical expenses paid in cash at time of service toward satisfaction of the deductible?

If you're not having the bill submitted to insurance, then you are responsible for the bill and it won't apply to your deductible. That's the whole point of having a deductible--you submit everything to insurance in the hope that you meet the deductible, and that insurance will eventually pay out. I haven't met my insurance deductible in years, but my husband and sister easily meet their deductibles each year and then insurance pays out in the thousands for their care.

[JRA64]

I have filed paperwork after the fact when I used Out of Network providers, pre-ACA, who did not take my insurance.

The one time I checked, after the fact, about filing a claim, both the provider and the insurance company wanted the provider to file the paperwork. I figured out it would have cost me more to file the claim than paying out of pocket so did not pursue it.

[goatmom]

We only take cash where I work.  People often ask for superbills to file with their insurance to count towards their deductable.  Not exactly sure if it differs from one insurance company to another since we don't get involved in that part of it.

What type of healthcare provider do you work for? And what do you mean by "superbills?"

Mental Health practice.  Superbill is what you file with your insurance to get out of network benefits.  It has the diagnosis code, the procedure code, the NPI number of the physician, and how much the patient  paid.  It is what a physician would send directly to the insurance company if the physician took insurance.

[goatmom]

Also, we charge to the same for every patient.  Anyone asking to negotiate a fee is told no and to be truthful is usually directed somewhere else.  In the long run, they usually are not happy with the paying out of pocket agreement. 

[AlwaysLearningToSave]

We only take cash where I work.  People often ask for superbills to file with their insurance to count towards their deductable.  Not exactly sure if it differs from one insurance company to another since we don't get involved in that part of it.

What type of healthcare provider do you work for? And what do you mean by "superbills?"

Mental Health practice.  Superbill is what you file with your insurance to get out of network benefits.  It has the diagnosis code, the procedure code, the NPI number of the physician, and how much the patient  paid.  It is what a physician would send directly to the insurance company if the physician took insurance.

Interesting.  It makes sense that you could do this to get out-of-network benefits since it seems the only efficient way to process such claims.  I would like to do this, except that I would do it even if the provider were an in-network provider. 

It just seems to me that the time of my rendering payment should not affect the determination of whether a medical expense is covered under the insurance policy.  I understand the insurer needs to receive the information from the superbill so that it can process the claim but why can't I pay cash-at-time-of-service and submit the claim to insurance after I have paid?  It may create an administrative headache for a traditional copay plan but for a HDHP it seems like time of payment would make little difference.

I'm doubtful it would work, though.  When providers have agreed to a lower cash-at-time-of-service price, I've wondered whether they are actually violating the terms of their preferred provider agreement with my insurer.  Asking for a superbill might press the issue and cause the provider to rethink the arrangement.

[goatmom]

Well, for most psychiatrist  the amount an insurance company pays them is not that great.  Many doctors that only take cash do so because they can keep their overhead lower by not hiring the staff needed to process the claims.  They can also charge a fee that they think is fair and run their practice the way they want.  I don't think the insurance company is going to have a doctor that participates with them do anything outside the norm. 

[Tjat]

Topical: http://finance.yahoo.com/news/cut-health-care-bill-pay-031100852.html

Apparently it's often now cheaper to pay upfront with cash then process through our insurance, despite the negotiated "discounted" rate

[AlwaysLearningToSave]

Topical: http://finance.yahoo.com/news/cut-health-care-bill-pay-031100852.html

Apparently it's often now cheaper to pay upfront with cash then process through our insurance, despite the negotiated "discounted" rate

Thanks for the article.  That is interesting.  It reflects my experience with smaller private-practice healthcare providers.  I have never tried it with a larger healthcare institution.  I imagine the larger the institution, the harder it is to negotiate cash up front. 

I've been surprised how willing providers are to talk about prices.  I used to think it was a taboo subject but now know otherwise.  If you just ask about prices and ask about a cash-at-time-of-service price, you can often gain ground without any sort of hard bargaining.  Asking about cash-at-time-of-service puts the provider at ease and gives them reassurance you are not going to stiff them.  Then if you approach the conversation in a polite and friendly, "I just want to understand your price structure and know I'm making the best financial choice" sort of way and not in an off-putting "Well the doctor down the street charges $10 less so match his price or I'm going to him" sort of way, chances are you'll be able to get a better rate. 

[Tjat]

Thanks for the article.  That is interesting.  It reflects my experience with smaller private-practice healthcare providers.  I have never tried it with a larger healthcare institution.  I imagine the larger the institution, the harder it is to negotiate cash up front. 

I've been surprised how willing providers are to talk about prices.  I used to think it was a taboo subject but now know otherwise.  If you just ask about prices and ask about a cash-at-time-of-service price, you can often gain ground without any sort of hard bargaining.  Asking about cash-at-time-of-service puts the provider at ease and gives them reassurance you are not going to stiff them.  Then if you approach the conversation in a polite and friendly, "I just want to understand your price structure and know I'm making the best financial choice" sort of way and not in an off-putting "Well the doctor down the street charges $10 less so match his price or I'm going to him" sort of way, chances are you'll be able to get a better rate. 

It does seem logical that health providers will engage in the same sort of supply and demand as normal businesses. It's funny that the concept of health insurance is so burdensome to providers that they'd just as soon avoid it.

One one hand, that supports MMM philosophy in that the consumer self-insures up to an emergency level. On the other, I'm paying $500 a month through a work-provided plan that still has a high deductible...