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Is it illegal to self pay when I have insurance?

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SiliconDawn

Junior Member
What is the name of your state (only U.S. law)? Colorado

I currently have insurance with a very high deductible. I would like to continue seeing a particular doctor (she's the only one who has been able to provide any help) but her office doesn't take my insurance (I used to have Medicaid which they take, but I no longer do). The financial office there said it's illegal to self pay if I have insurance, that they are required by law to bill insurance. Is this true? If I told them I don't have insurance even though I do, will I, or they, actually get in legal trouble if it were discovered?
 


justalayman

Senior Member
I’m missing something. You said they don’t accept your insurance so just who would they file s claim with?

And illegal to self pay?

Especially since they don’t accept your insurance that just makes no sense.
 

SiliconDawn

Junior Member
I was confused too. They said that since they don't accept my insurance they couldn't see me at all anymore since it would be illegal for them to see me as a patient because they are required to bill insurance if I have it. I asked if I could just self pay so they wouldn't have to bill insurance and that's when they said it was illegal for me to self pay if I have insurance. Now with it being the new year my insurance has changed (though still not something they accept) and I was considering going back and just telling them I no longer have insurance at all, but I don't want to do that if I really could get into legal trouble. I've never heard anything like this before so I'm just at a loss.
 

justalayman

Senior Member
I must be really missing something as it makes no sense. Stick around. There are a couple HR people that know quite a bit about the insurance game that post here.
 

SiliconDawn

Junior Member
It makes no sense to me either. I see no reason why I MUST use insurance just because I have it. If I want to pay out of pocket why would that be illegal? I just have no idea. But I don't want to get into trouble if for some reason it is illegal. I'll wait around and hopefully someone else will have more info. :) Thanks.
 

adjusterjack

Senior Member
Doesn't make any sense to me either.

There's nothing illegal about self pay, even when you have your own insurance.

Even if that provider doesn't "take" your insurance there's no reason that they can't just give you a receipt for your payment and then you turn it over to your insurance for reimbursement or to meet your deductible if the treatment itself is covered.

I think there is something else going on.

Either you are talking to an idiot or that provider just doesn't want you as a patient anymore.
 

SiliconDawn

Junior Member
I suspect I was talking to an idiot. The provider I was seeing was sad to see me go but unfortunately she had no control over the policies of the office. Since it's a new year, and therefore feasible that I may have lost my coverage at the beginning of the year (which I did, in a way, I no longer have the same insurance company), I think I will go back and simply tell them I no longer have insurance. See how it goes from there. They did tell me to come back if my insurance status changed. Well, as far as I can see they have no need to know what insurance I have now. I'm more than willing to pay out of pocket. As long as I'm not breaking any laws then I'm going to do that.
 
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cbg

I'm a Northern Girl
I'm one of the HR people that JAL was talking about. I've been working with employer-sponsored health insurance benefits since 1979 and I've never heard of any law that makes it illegal to self-pay if you have insurance. On the kind of insurance you have, you've going to be self-paying for a long time even if they do bill the insurance. And if they bill the insurance and they're denied for being out of network, you're still going to have to self-pay.

If you have the kind of plan I think you have, there is still some level of coverage even if you go out of network (it's just that the deductible gets even higher and the percentage of what is paid when you meet the deducible is smaller). So I have no idea what she thinks she's talking about.
 

LdiJ

Senior Member
I agree with the other two responders. I am not in HR but my dad was and insurance agent and so is my sister in law, and I have never heard of it being illegal to self pay either. In fact, I cannot imagine why a state would even try to put such a law in place. It makes no sense.
 

LdiJ

Senior Member
Ok...I did think of one thing, but its pretty farfetched.

What if an insurance company required, in their contract with the provider, that everything be billed through insurance first, so that the medical condition was noted with the insurance company, and the employee at the doctor's office mistakenly translated that into "all things must be billed through all insurance companies first or its illegal"?

I also think that medical providers act like wimps when they let their office staff determine procedure. They do that to isolate themselves from the mundane, business aspects of their practice, but it makes them look like wimps to anyone who has any business experience at all.
 

Just Blue

Senior Member
Ok...I did think of one thing, but its pretty farfetched.

What if an insurance company required, in their contract with the provider, that everything be billed through insurance first, so that the medical condition was noted with the insurance company, and the employee at the doctor's office mistakenly translated that into "all things must be billed through all insurance companies first or its illegal"?

I also think that medical providers act like wimps when they let their office staff determine procedure. They do that to isolate themselves from the mundane, business aspects of their practice, but it makes them look like wimps to anyone who has any business experience at all.
:rolleyes:

//////////////
 

PayrollHRGuy

Senior Member
Ok...I did think of one thing, but its pretty farfetched.

What if an insurance company required, in their contract with the provider, that everything be billed through insurance first, so that the medical condition was noted with the insurance company, and the employee at the doctor's office mistakenly translated that into "all things must be billed through all insurance companies first or its illegal"?
The provider doesn't have a contract with insurance company. If they did they would accept the insurance.
 

xylene

Senior Member
When someone is serving you claims something is 'illegal' or against a formal policy...

Politely but firmly insist that they provide you with the text of, or at least an explanation of, the relevant law or policy, in writing.

They are denying you service, medical care at that. Asking for a written explanation of the denial is a very legitimate and reasonable thing to expect and insist on. Particularly when the thing claimed to be 'illegal' seems reasonable and straightforward.

That's not to say they have to do this, but it really helps to understand what is going on and sort out whether someone is just overly officious, stupid, or both or more.
 

cbg

I'm a Northern Girl
It's probably something along the lines of what LdiJ said; not a contract with the provider for the reason PayrolHRGuy said, but some office policy that the office person thinks is a law.
 

PayrollHRGuy

Senior Member
The OP could simply tell the doctor that they want to pay in cash, "I no longer have insurance." If talking to someone at the doctor's office with a clue isn't an option.
 

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