Insured but not letting the doctor know?

I’ve been incredibly negligent in posting here the past several months, hopefully getting down to one job will allow me to post here more frequently (and yes, I’ve said things like that before).

Today I wanted to address something I’ve gotten several e-mails on over the past few weeks. Early last year I put up a post titled “Insured patients can save money by pretending to be uninsured.” The gist of the article was that the negotiated rates paid by insurers to doctors are sometimes more than the cash price the same doctor might charge someone who is uninsured. In those circumstances, for people who are going to be paying the full bill because it’s under their deductible, it’s better to hide the fact that you have insurance and just pay the cash price.

The question I’ve gotten a couple of times recently has to do with the legality of doing this, and what might happen if the doctor finds out you are insured. The answer to the first one is easy – it’s completely legal to not use the insurance you have, or at least I’ve never heard of an insurance policy requiring that their policyholders use them for all treatment.

The second one can be a little tricky. A couple of people have told me that they’ve tried to get the cash price after they have given their insurance information, only to be told they have to charge them the negotiated rate. Unfortunately, this is true, even though the patient will be paying the full price, whatever that may be. Once you tell a doctor’s office you are insured, they are contractually obligated to charge you the rate they agreed to with the insurer.

Someone else described the following scenario: they’ve been getting the cash price by not telling the doctor they are insured, what happens if they find out they’re insured? Will the doctor go back and have to re-price all the past bills? Two thoughts.

One, it depends on what exactly the doctor finds out the patient is insured. If they only find out that now, as of this particular visit the patient is insured, they’re likely going to assume it’s new coverage and not ask about whether past visits could have been covered under the insurance policy as well, so this shouldn’t be a problem.

If, on the other hand, the doctor discovers the policy was in effect during previous treatments, there might be a problem, and I just don’t know what might happen. Some doctors might opt for a “water under the bridge” attitude and not worry about it (there’s not much financial incentive for them to pursue the higher charge, as the marginal increase in revenue is likely to be gobbled up with the bureaucratic hassle of going back and dealing with it), while others may insist on going back. It probably depends on the doctor and how devoted they are to the third-party payment system (if they were offering good cash prices to begin with, the answer is probably “not very”).

I’d be interested in hearing any experiences anybody has had that relate, shoot me your thoughts at selfpaypatient [at] gmail [dot] com.

This entry was posted in Cash-Only Doctors, High-deductible health insurance. Bookmark the permalink.

50 Responses to Insured but not letting the doctor know?

  1. DoctorSH says:

    Insurers, hospitals, Big Pharma and government have too much to lose to make the system more transparent. Thus the need for the third party involvement making people dependent on a dysfunctional system.

  2. Hi Sean,

    The legality of this is not really an issue with the patient, but it certainly is with the provider. A doctor/clinic that is a medicare contracted provider (whether they accept assignment or not) is REQUIRED to bill for medicare services. The only exception is if they opt out of Medicare. And Medicare patients are required to notify providers that they have medicare coverage. A provider who has a managed care (commercial, ie: Blue Cross) contract with an insurance carrier is bound by that contract to file claims on behalf of the patient. If they knowingly avoid filing, they can be kicked out of the plan. And of course, the key word is “knowingly”. Obviously if the patient does not tell the provider that they have insurance, then the provider will naturally treat them as a cash patient. BUT, if the patient, later on in the year, decides to self file (because maybe now they have met their deductible, and want to be reimbursed for services they paid cash for), BOTH the patient AND the provider can find themselves in trouble. The patient may not realize this is actually fraudulent, and the provider will be questioned as to why they did not file, per the contract. The provider will then have to explain that the patient did not inform him/her that they had coverage, and possibly require an affidavit from the patient attesting to this.

    The best course of action for the patient who does not want to use their insurance, would be to inform the provider of this. The provider may then have the patient sign a WAIVER TO FILE INSURANCE. This way both entities are covered. In this waiver, the patient will confirm that they do not intend to self file, nor ask the provider to file on their behalf at a later date. Hope this information is helpful!

    Lisa Maciejewski-West, MCS-P
    President, Gold Star Medical Business Services

    • says:

      Thanks for this clarification, as you note it is all about “knowingly.” And Medicare is a whole different issue, I wouldn’t even think about trying to pretend to be uninsured when dealing with a Medicare situation!

      • Sean, what about Medicare Advantage plans? This is an area of confusion for me and my staff. These plans are really “PPO”s but shrouded in Medicare promises with unclear rules. As a present provider, can I treat these folks as private insurance? If not why?

        • says:

          I’m not that familiar with Medicare, but I’d assume they fall under the Medicare rules, not those governing privately insured patients.

        • Hi Dr Kordonowy,
          The best thing to do is to verify each and every Medicare patient’s benefits for all insurance cards they have in their possession. This means that you can discern whether they have traditional Medicare coverage with a red, white, and blue card, or have decided to choose a Medicare Part C plan.If so, you must know whether or not you participate in this plan, and whether they have out of network benefits if you don’t. Watch out for ID cards that say, “PFF,” which stands for Private Fee for Service. If you treat and submit bills for services on one of these patients, you are automatically in the network while treating that patient, and subject to all the fee restrictions and appeals processes of this plan. It’s also known as making you a “deemed provider.” If you don’t want to accept these benefits and you are not participating in their network, then let the patient know you are not submitting to the PFF carrier,and then you may treat that patient as a cash paying patient, and NOT be restricted to the fee schedule of that carrier.

    • Nikki Diebolt says:

      I am so confused over this whole issue and it seems from all the articles I’ve read it seems to be a what the insurances don’t know won’t hurt us attitude about this issue. You said that “A provider who has a managed care (commercial, ie: Blue Cross) contract with an insurance carrier is bound by that contract to file claims on behalf of the patient. If they knowingly avoid filing, they can be kicked out of the plan.” Your answer to this was “The provider may then have the patient sign a WAIVER TO FILE INSURANCE. This way both entities are covered.” Please tell me how having a patient sign a WAIVER TO FILE INSURANCE covers both entities.” I have had this argument with our local BCBS carrier and was informed that the patient has a contract with their insurance company to use their insurance with any contracted provider and the provider has a contract with their insurance company to bill their insurance for any of their subscribers. So please advise how this “waiver” helps keep us from getting our contracted voided by the insurance carriers?? THANK YOU!!!

      • I wouldn’t put much credence on an insurance agents explanation of self serving rules. Furthermore if contracting with an insurance provider is so confusing and harmful to your business as to defy common sense, I ask” why sign a contract”? Because these contracts are so heinous I stopped signing private health insurance contracts nearly 16 years ago. Only doctors sign contracts that are harmful to their business and ethics.

        Second point, PPACA did not mandate that providers participate in an insurance contract. Doctors could end this whole fiasco by tearing up their contracts. What an obvious choice to correcting an inexcusable injustice. Anyone care to join me?

  3. I think we had some of these situations during my 18 years in private solo practice. My wife’s solution was simple, and came from experiences at the food checkout by employees at large supermarkets: When the employee erred in keying in the wrong product and my wife corrected the employee, a supervisor was called. The supervisor questioned the employee unmercifully in front of many customers and caused great embarrassment to all who witness this. The employee tried to remain unaffected, but my wife could see the “Stink eye” she got as the checkout proceeded. So, next time something like that happened, my wife said nothing, and there were no repercussions . . . no matter that the pine nuts at $12/lb were rung up as great northern beans at $0.29/lb. Nobody lost face. Everybody happy. (smile)

  4. Great post. Timely issue. In essence, we are having this discussion because contractual CPT based third-party billed charges are exposing the “cartel” for what it is: a legal monopoly with price fixing. Patients & doctors are starting to realize that billing claims as it is done in most medical practices is what is driving prices by forcing everything through the insurance claims cycle. They are essentially pricing themselves out of the market.

    Like you say, there is no law that requires a person to use their insurance. I think it gets down to intent and how the paperwork at registration is filled out. If patient provides insurance information for the “record”, this implies a desire to use it and provider has some obligation to follow network contract rules. If the discussion about fees and payment is done preemptively, with choices and options given ahead of registration, I think it would be irrelevant if the doctor “knows” the patient has insurance; as long as the patient made an informed consent to use or not use based on fee structures. This is how an open, free market is supposed to work.

    • DoctorSH says:


      The powers that be do NOT want a free and open market.
      A free and open market is something they can not control politically.

  5. Jerome Bigge says:

    In France the patient pays the doctor, then collects back from the insurance company. A smart card is used (one that contains the patient’s medical data) so the doctor does not need the “staff” that is necessary here in the US. Plus the system is completely computerized and apparently considerably “simple” compared to our own.

  6. Before September of 2013, patients did not have a choice whether or not they wanted to use their insurance. It was a problem for patients and physician offices. Now, patients have an option and medical offices are relieved!

    If patients opt out of using their insurance for a visit or service, the practice can charge whatever they want. I’ve strongly recommended, however, that practices charge the self-pay rate because they are getting paid in full at time of service AND there is not insurance filed – a win for the patient and the practice. I’m afraid any practice that is charging patients who opt out the full “retail” rate or the allowed amount is taking advantage of the situation.

    Mary Pat

    • David Schneider says:

      Hi, contrary to all the other commentary this appears to be a simple explanation. The patient has the choice to either user or not use insurance for a visit and the provider can charge whatever they want. What happened in 2013 and is there some law that I can share with my provider? They certainly don’t see it that way! I have had two visits which have cost me substantially more by submitting to my insurance as opposed to the self pay cost.

  7. Hi Sean. Since I last commented, I have changed my practice name and remain a cash friendly doctor. This whole discussion underscores how ridiculous the system is. For insurance companies to legally bind providers to rigid pricing illustrates the lengths this industry will go through to control the market. If you chose not to involve your insurance company in settling a mutually agreeable exchange for health care, how is that any different than paying for your car repairs after an accident in order to avoid higher future premiums? This decision analysis is one way market participants can demonstrate their risk tolerance.

  8. GKeys says:

    I am currently in a clinic that take insurances, but I am thinking about opening another clinic in the next town over. In the new clinic I want to charge cash only. Do I have to change names/Tax ID. I am so informed with all the dialog. I appreciate any input. Is it good for small towns?

    • says:

      I’m not sure you have to change names, although for marketing purposes it might not be a bad idea. As for the Tax ID, I’d consult a tax or accounting professional, but I wouldn’t think so.

      • If you set the clinic up as a satellite clinic, you should be able to have it under the same Organization (Type 2) NPI and Tax ID. I agree that it would be best to consult with an attorney to make sure the structure of the organization is legally correct.

        Lisa Maciejewski-West, MCS-P
        President, Gold Star Medical Business Services

  9. t says:

    The ‘ narrow networks’ of my ( platinum!) policy plus the number of drs refusing to accept ‘obamacare’ in TX I expect to have to pay for at least some of my care because it’s too difficult to line it up.

    Like my recent experience of visiting a specialist office to find his office practice is covered- a place purely for consultation- but the hospital clinics where he can perform procedures are not…he charged over $300 to tell me in 10 minutes the same thing as my gp did…then I’m going to have to go through the same process again.

    And we wonder why US medicine is so costly.

  10. The HITECH provisions in HIPAA allow a patient to restrict information to their insurance company if they opt to pay cash-in full at the time of service. Here is a paper that talks about this.

    • Thanks- it appears that if we just pay for our care we can tell all the 3rd parties to “step off”. As it should be. When are both parties in the exchange (doctor and patient ) going to tell everyone else to get out of the exam room?

  11. This is an interesting dialog that goes against what I’ve learned and have been advising my private practice clients. It is my understanding that an office sets *one* fee schedule that they will charge *all* clients unless, and only unless, that client is a member of a group with whom the provider has a a different contractual arrangement. In other words, if I want to charge $240 for an exam, the only people who don’t pay that are people who are members of some group with whom I am contracted to charge something else. If I were to set a “cash-pay” exam price at, say $120, this would be considered having dual fee schedules which I understand are illegal.

    Per my understanding, there are a couple of ways this plays out:
    1. if your contract states you must bill the plan for services
    2. if your contract has a “Most Favored Nation” (MFN) clause, which generally means that you agree to charge the insurer no more than you charge others.
    3. if you are a provider for any of the gov’t plans like BCBS Fed or medicare/medicaid

    The first one is obvious and what this article is about.
    But 2 & 3 are tricky. If an insurance plan learns of your dual fee schedule approach, they can demand the difference back–I’ve certainly seen this happen to more than one practice here in Anchorage, Alaska.

    The OIG ruled that a 10-15% book-keeping reduction for patients who pay at the time of service is considered reasonable; patient must pay in full same day because the idea is the savings on all the administrative accounting and billing.

    But the folks who had to pay back money (and I’m talking $30-50,000!) were setting a “cash” price of 20-60% lower–which makes sense given the hassles of insurance–but may not be legal. What they were *not* doing is setting up any other sort of contract with those patients–like a Discount Medical Plan or office-managed membership agreement that would entitle the patient to lower rates for a reasonable membership fee… they were running a true dual fee schedule.

    And how they were caught is when patients requested receipts–which they really are entitled to get–and then self-submitted those to their insurance plan when later that year they had met their deductible.

    I’m not an attorney. I’ve helped a few practices set up and smoothly transition to membership plans and studied the issue. Would love some feedback. Has something changed?

    • says:

      It’s tricky, but navigable. I’m not an attorney either but what you’ve explained is basically correct, with a whole lot of caveats. First, it’s not “illegal” to the best of my knowledge to have a cash fee structure, but it can be a violation of the contract with an insurer. The most obvious way out of this is to not accept insurance. For those that do, the simplest option is to set their cash prices at the same level as their “negotiated” rate with insurance companies. Different insurers pay different rates, of course, so you may need to set it at the same level as your best-reimbursing insurer (which may vary by procedure/treatment). If Humana is the most generous with a $70 pay for a level II visit, set your level II fee at $70. If BCBS is the best payer for level III, set your cash fee at the BCBS rate. The problem arises (and this is where doctors offices create their own problems) when they simply pick a high number – say, $150 for a level II visit – and then tout their more-than-50%-discount to the Humana rep.

      There’s also the membership plan option, of course, and who’s to say a provider can’t sell their discount membership for $1 at the time of the visit? In Virginia you have to be a member of a gun club to use the range, fortunately memberships cost next to nothing and are sold at the same time you rent your lane…

      So, it’s one of those things where if the provider isn’t careful, yes they can run afoul of their insurance contracts, but there are some pretty easy outs, starting with not accepting insurance.

      • This complexity is ridiculous. It begs the question why contract with any “group” or insurance. Like any product we should have the right and legal support to provide our services at whatever price we deem the market will bear and that we are willing to provide it for. I think myths are created out of all this “third party rules” dialogue.

        Dr. K

    • Marie, you are correct in your assessments/statements. A clinic/organization should have ONE posted fee schedule in their system. And the bookkeeping discount of between 10-15% is also correct. It can actually go as high as 20%. But the caveat to this is that the patient must pay at the time of service (to reduce/eliminate bookkeeping fees of filing claims, sending statements, etc), and this discount is not valid on copays, coinsurance or deductible amounts. This is a CASH and CARRY discount only. One way that a clinic can offer deeper discounts is by participating in a valid CASH DISCOUNT or Medical Cost Sharing program. The patient basically pays a “membership” fee to this organization (it can be as low as $25/yr for an entire family). The provider either sets their fee schedule with the organization, or the organization provides a cash fee schedule that the provider must honor. In this way, the provider/clinic essentially has a “contracted cash rate” the same way they have a contracted insurance rate with carriers with whom they participate.

      • Joshua says:

        Ah but 1) getting paid immediately, 2) not dealing with the insurance at all, and 3) not having to do the much higher documentation required by insurance companies makes the effective cost reduction for cash more like 50% than 15%.

        • Hi Blaine. The reason why a doctor can charge slightly more for insurance cases vs. cash cases relates to how medical fees are legally structured. Each service that is provided by a physician or health care practitioner is valued by the following formula: 75% of the fee represents provider expertise/level of direct interaction with the patient, 23% represents administrative costs associated with billing and managing the service/claim, and 2% represents malpractice insurance that must be carried in order to perform the service. So the Office of the Inspector General (OIG), the government entity that rules over Medicare/Medicaid and all federally funded programs, deemed that it is acceptable to charge around 15% less for services provided to cash patients who pay their bill at the time of service because it essentially eliminates the administrative portion of the fee. And most commercial payers (Blue Cross, United Healthcare, etc) follow the same rules.

          With all that said, since I am assuming you have paid for the services, and all you are doing is asking the doctor’s office to provide a “superbill”, as it is known, and you are going to file yourself, I think an additional $25 per visit to prepare that superbill is pretty excessive. Most practice management software programs are designed to print those when a patient checks out, in the event you decide to file yourself. As a matter of fact, most providers who are not in network with an insurance plan, will provide this as a matter of course at checkout. This way they do not have to deal with having a patient come back and ask for one later. Hope this helps explain what is going on with your situation.

          • Blaine says:

            Lisa thank you so much for the explanation. It’s extrmely helpful. What confuses me is they claim that even with the superbill, I can file for the insurance and still have to pay them the $25. On top of that, they claim the fee structure as it relates to insurance patients is tied to their NPI and TAX ID number, and the “have to” charge me for the insurance fee even if I file. That’s where I have issue, is the “have to”. Do they “have to?” Because of why they say?

            And I’ve pre paid for all services rendered. And even if you pay them the insurance rate. You have to pre-pay. That’s what makes the thing so silly. The process and things are exactly the same for either the insurance or non insurance rate, but they give you a superbill.

            I spoke to the Secretary of State who grants licenses and they pointed me to the law which states: “Licensees shall charge only for services rendered and shall provide itemized statements for charges for goods dispensed and services provided to the consumer. Nothing in this Rule shall preclude requests to the consumer for prepayment of fees for service as long as fees are refunded for services not rendered. This Rule shall also not preclude requests for appointment deposit charges when the consumer has received prior notification of this charge policy.”. This is the rule below

            Again, these people are not in network with ANYONE.

            Thanks for the help everyone.

  12. DoctorSH says:

    Just opt out of all third parties and set your fees appropriately at where you think your value is to your community.
    This bypasses this whole argument/debate.

  13. DrHarris says:

    I am considering entering private practice for the first time in the near future as a podiatrist. I wonder how feasible it is to start a cash only specialty practice. My strategy would be to aim for patients who have high deductibles and can get the same services from me for less than they would pay using insurance. It seems the best way as a new practitioner is to avoid all insurance contracts. My question is, being a specialist, would this be more difficult versus being a primary care provider?

    • says:

      I know of plenty of specialists who go cash-only, so it’s certainly feasible, and I’d think a podiatrist wouldn’t have too much trouble. I suggest you contact the Association of American Physicians and Surgeons, they have seminars and materials for doctors considering going cash-only.

    • Dr. Harris,

      A cash practice is very feasible, but keep in mind the number of Medicare-age patients podiatrists usually see. It is quite rare for a Medicare patient to sign a contract to pay cash, as they will have to do if you opt out of Medicare, which you will be required to do if you want to see Medicare patients but will not file their insurance. What about your surgical patients?

      If you have an established panel of patients and believe that many of your current patients will stay with you as you convert to cash, then you are in an ideal situation. Cash practices that start from scratch can often take awhile to build so I advise physicians to invest heavily in digital marketing (website, Facebook, etc.) and offer something that no other provider in your specialty has so patients are motivated to flock to you!

      Best wishes,

      Mary Pat

      • says:

        Should have mentioned, in addition to AAPS, talking with Mary Pat is probably a good idea too, as she has some knowledge and expertise in this area. And she’s right about Medicare, if a substantial portion of likely patient base is in that program it gets very complicated.


      • Hi Mary Pat. To expound on this.
        Opting Out of Medicare

        A physician or practitioner may opt out of Medicare and enter into private contracts with Medicare beneficiaries. When a provider opts out of Medicare, no services provided by that individual are covered by Medicare and no payment can be made to the physician or practitioner or to beneficiaries except for services provided in an emergency/urgent care situation (see guidelines below). Only individual providers may opt out of Medicare. Group practices and organizations may not opt out.
        Private Contracts

        A private contract is a contract between a Medicare beneficiary and a provider who has opted out of Medicare for two years for all covered items and services furnished to Medicare beneficiaries. The beneficiary agrees to give up Medicare payment for services furnished by the provider and to pay the provider without regard to any limits that would otherwise apply to what the provider could charge.

        • We all need to question why and how we allowed our personal money (whether as deferred potential salary offered as “benefits” or provided as individual premiums) to be confiscated by a third party health insurance company only to have this capital “held” from the point of care. It is unbelievable that we have given up our rights to access the health care market on our terms as consumers.

          Dr. K

          • ER-DR says:

            This. This is what happens when enjoy the relaxing warm water we’re sitting in… In the pot on the government stove. Feels good at first, but by the time we realize what’s happening we’re too weak to jump to safety.

          • Agreed. It’s also like the story of capturing all the hogs in the town. Put the food out then after time build a fence around the food. Voila all the hogs are captive.

          • Pamela says:

            Sorry to interpose this is inappropriate; I am trying to wade through the dross of Medicare info. My husband is turning 65 and our medical sharing org (CHM) insists he must sign up for Medicare in order to continue with them as a Medicare Supplement. My questions:
            1. MUST we sign up for Medicare? Is there any way to opt for total self-pay? Any other option?
            2. If the law is such that we must do Medicare, can we forego using it…?
            3. As an aside, we live and work overseas and will likely remain overseas…so is there a way to opt out of Medicare because of location?

  14. Dale Fenwick says:

    Before scheduling the procedure I told the doctor, the out-patient facility, and the anesthesiologist that my screening colonoscopy was not covered by insurance and I was a self-pay patient.

    The doctor understood and gave me his self-pay rate. I paid him. After several calls the facility finally told me one amount, which I paid the day of the procedure. They then sent me a bill for $350 more. When I questioned the amount they said the self-pay rate was $75 more, but I did not qualify. More on that later. I paid $75 more.

    The anesthesiologist’s office would not tell me the self-pay rate before the procedure and revealed the self-pay amount in the bill sent after the procedure, but only after I questioned the billed amount. I paid the self-pay amount.

    Without my permission or request the facility and the anesthesiologist sent their bills to Medi-Share who re-priced the original bills using whatever pricing they use. I assume they got the Medi-Share info from the doctor’s office. I did not give it to them. The re-priced amounts are higher than the self-pay amounts. I have refused to pay more than the self-pay amount. The bills have been sent to a collection agency.

    I say that I have paid them the agreed amount in full. There are no written contracts between me and the providers who typically reveal their pricing only after providing their services. If I was an automobile state law would be on my side since there no “good-faith” estimate was provided before the work was done.

    The providers say that because a polyp was found during the procedure the screening colonoscopy became a diagnostic colonoscopy which is “shareable” under Medi-Share’s guidelines thereby making me ineligible for the self-pay rate. But I am well-below the shareable threshold therefore I am completely self-pay. Moreover, Medi-Share is not insurance and has no contracts with providers.

    I guess the moral of the story is this: Keep asking for the self-pay rate. Do not schedule the procedure until you get it.

    Not sure how best to deal with the collection agency since they are trying to collect an amount I never agreed to pay.

    • Another moral of the story is that the physician’s will now need to start explaining that dealing with a finding does change the service complexity and therefore the price of the service. The doctor could have noted the finding, woke you up then explain that a repeat therapeutic procedure is now required- essentially another bowel prep, then a dedicated colonoscopy to the lesion, snare and removal and need to send the specimen off for pathology clarification. Different polyp tissue types result in different followup recommendations and future cancer risk. While your abnormal finding resulted in a mildly higher charge you were still getting a smoking deal. In my opinion you should thank your doctor and his facility for taking all things into consideration and providing you with a very fair and efficient service and workup . I would recommend you pay the fee and send your doctor a thank you and gift card to boot.

      • Dale Fenwick says:

        Point taken. But my beef is not with the doctor, who billed me and was paid his self-pay rate for a diagnostic colonoscopy, including the lab charges for the polyp biopsy. I agree, once a polyp is found the doctor has extra work and deserves extra pay.

        I am willing to pay the facility and the anesthesiologist their self-pay rate. My beef with them is two-fold:

        1. They refused to provide me with the self-pay rate prior to the procedure.

        2. When they subsequently revealed their self-pay rates they said I was not eligible for the rate because, according to the facility and the anesthesiologist, Medi-Share told them the charges for a diagnostic colonoscopy were shareable. I called Medi-Share and they read me their standard statement for providers asking about coverage. The statement confirms I am a member but does not guarantee that any procedure is shareable.

        I am still trying to figure out how best to deal with a collection agency trying to collect monies I never agreed to pay.

        BTW – I have found another facility in Orlando that publishes their self-pay rates. The rates are higher if any polyps are found. The “menu” of self-pay rates seems to cover all conceivable outcomes.

        • Terrific.

          It is difficult to know ahead of time all contingencies. I personally am unfamiliar with Medishare and the specifics you are dealing with. I would prefer no third party in any of these transactions. I totally agree that for true price transparency all parties involved in your care need to have been disclosed prior to your procedure.

          I understand for instance the Oklahoma Surgical Center model includes “all in” fees. I agree getting an a la carte bill after the fact would be upsetting. Both the provider and you the consumer can learn from this situation.

          Dr K

  15. t says:

    Well it took months, and United Healthcare refused to pay despite acknowledgement from several of their operatives that they were responsible for a $290 bill balance. I fought and fought them but they are one corrupt/incompetent company that’s for sure…anyway the doctor office upon learning I plan to make a complaint to my state’s health insurance commission lowered the outstanding bill to $120, which is what I would have paid cash on the day. I didn’t ask for that- the admin volunteered, sympathizing with me that my health insurance is so crappy.

    Weirdly, United Healthcare have now taken to calling customers up and offering us ‘free ‘ advice on our health needs…I won’t be taking them up on anything- I doubt it will be with any altruistic purpose in mind- and will be dropping them asap when the new year enrolls. In fact I might as well have no insurance, pay for my own tests and doctor visits, and pay the government fine than purchase their insurance in 2016.

    The networks being so narrow and the insurance co lists of facilities being inaccurate, I don’t think there is anything duplicitous about visiting an office as a cash-pay patient. In my case almost any doctor or hospital I choose to see in my huge city isn’t covered on my current policy- and I can’t trust United Healthcare when even when they tell me to go to a practitioner they then refuse the bill.

    Evil times we live in!

  16. Is that true? I doubt that could even happen. How did we ask for a claim then if there is no proof in the first place from the hospital?

  17. I meant to post this reply to your comments earlier.

    I am perplexed as to why we take our personal money (either by individual insurance contract or by deferred salary as an “insurance benefit”) and give this to a third party, only to have them not honor your tacit contract to receive care from a provider. The rules of denial defy logic and any real market based transaction. I continue to suggest we in the consumer sector should decline the traditional and mandated insurance model on moral/ethical grounds and as a demonstration of peaceful civil disobedience (in the setting of the mandate).

    Dr. K

  18. Blaine says:

    I could use some help if anyone is still looking at this thread.

    My son has been seeing a speech therapist since early this year. The provider is not contracted with any insurance company, but has a $150 “insurance rate” and a $125 self pay rate. Note, that the insurance rate is not a charge to file the insurance, I the patient still have the ability to do that. During our first visit, we paid the $150 rate and filed insurance, thinking it would never get paid. Since then, 30+ visits later, all at the $125 rate (not known to me that they were charging that for various reasons), we finally got insurance to agree to pay it. So now we are stuck with 30 visits paid at $125, and 1 visit which was filed with insurance, and the full $150 was allowed. I asked the provider to provide me with the bills and I would file the insurance myself, and she insisted that I pay her the remaining $25 per visit and THEN I or she could file it. She’s claiming it has to do with her tax ID, her NPI, and Medicaid ability for reimbursement.

    The $25 is not a charge to file insurance. I can do that myself. Since she’s not contracted with anyone, I don’t see how this is proper practice.

    Thanks for the help

    • Fedup says:

      That sure sounds like extortion. Call your local media and ask them to investigate. It’ll take one phone call from them to the Dr.’s office and they’ll buckle. They don’t want that kind of exposure.

      • Joshua says:

        Doesn’t sound like extortion to me. They are charging less for cases that would not be looked at by insurance. Now they will be. Self pay is self pay.

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