Are HDHP policyholders actually "disallowed" from self-paying?

Non-investing personal finance issues including insurance, credit, real estate, taxes, employment and legal issues such as trusts and wills.
Topic Author
paws
Posts: 24
Joined: Sat Dec 02, 2017 9:54 pm

Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

TL, DR:
If a patient visits a provider (say as an outpatient), has health insurance but doesn't want to use it, are they disallowed from choosing to self-pay and not use their insurance?

Back story:
A receptionist at my local dermatologist office told me this wasn't allowed on my visit today. Been quite a while since I visited a specialist so I'm wondering if I'm ignorant of something new.

For context I'm in my 30s in NJ, self-employed, no chronic conditions, generally healthy on a Silver individual plan I got on the marketplace. I learned about HDHPs and HSAs (here on BH, thanks) so am doing that for the first time this year. Plan has a $2k deductible and excepting the unforeseen I don't anticipate reaching it. My plan was to call ahead and ask providers the difference between self-pay/cash rate vs insurance rate, so I could make a more informed financial decision.

When I called ahead to inquire about my derma visit, she said self-pay cash price was $200-250, but she wouldn't/couldn't say the insurance side. Did I say how much I love American health insurance? #1 in the world. Undeterred I asked again as my visit concluded at checkout time, presumably when provider should have picked the procedure codes.

Surprisingly, she told me that if patients have insurance they are "disallowed" from self-paying. I asked her what law covered this but she couldn't tell me. She said she's "been doing this for many years and that's how it is."

Is she correct?

Quick Googling suggests if this and this are to be believed, Section 13405 of ARRA suggests the opposite.

She went as far as to say were I to try and pay cash "the insurance company would find out anyway."
The only way I see that being true is if the provider were to automatically share my case/PHI with the insurance company, which presumably is the default for lots of folks. Pretty shocking how much power the insurance companies are granted in the patient/provider relationship, by default.

In conclusion, I think she was wrong. EDIT: she probably was not wrong. Please see viewtopic.php?p=7235935#p7235935
But very important, if I'm understanding the ARRA correctly, it's critical that you not give consent to have your PHI shared with any entities. Quite a gotcha to know ahead of time.

Will appreciate any thoughts, thanks!
Last edited by paws on Mon Apr 24, 2023 10:14 pm, edited 1 time in total.
volstagg
Posts: 245
Joined: Tue Feb 01, 2022 7:28 am

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by volstagg »

I had a similar experience years ago at my primary care. While they took all major insurance policies, they had self pay options clearly posted, including for their in house blood work through LabCorp. From past experience I knew it was a better price then the negotiated rates my insurance provider had with LabCorp, but they wouldn't let me use them, if I also had health insurance.

Basically, I couldn't use my health insurance to pay the doctor, then pay for the blood work via their self pay plan.

When I inquired as to why, I was told that the agreement they had with the insurance provider (Cigna) prevented them from allowing patients to pick and choose what went through insurance coverage. If they were ever audited (which is something I guess Cigna is entitled to do under their agreements with providers) and it was determined that one of their subscribers (me) paid out of pocket for some services and used insurance for others, they could have Cigna cancel their in-network agreement and then would loose access to ALL Cigna customers as in-network.

I expect other insurance providers (Humana, United Health Care, etc) have similar clauses in their agreements.

Health insurance is a game, like loss leaders at a retail store. They might have some really good negotiated rates on some common services and make up the difference for other things. In my case, my primary care visits when paid through insurance negotiated rates were less than paying out of pocket, but my blood work was more (even though both were through LabCorp and the phlebotomist was right in their office). If they (Cigna) let customers just pay out of pocket for certain services when it was cheaper then using insurance, they might actually lose money (or at least not make as much money :happy ).
User avatar
Artsdoctor
Posts: 6063
Joined: Thu Jun 28, 2012 3:09 pm
Location: Los Angeles, CA

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Artsdoctor »

If the physician is enrolled in your particular plan, the physician is not allowed to charge a cash price. For example, if I'm (as a physician) enrolled in a Blue Cross network and a patient is seen in my office, I'm obligated to run the visit through the insurance and I must accept the negotiated rate. The patient doesn't really have a say in the matter. Certainly you can imagine that a Medicare provider cannot bill the patient for a cash visit--and the Medicare patient cannot "turn off" her Medicare policy with a physician who's a Medicare provider.

However, if the physician is not part of the plan, the patient can certainly pay the cash balance at the time of the visit.
hachiko
Posts: 941
Joined: Fri Mar 17, 2017 1:56 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by hachiko »

volstagg wrote: Mon Apr 24, 2023 7:39 pm Health insurance is a game, like loss leaders at a retail store. They might have some really good negotiated rates on some common services and make up the difference for other things. In my case, my primary care visits when paid through insurance negotiated rates were less than paying out of pocket, but my blood work was more (even though both were through LabCorp and the phlebotomist was right in their office). If they (Cigna) let customers just pay out of pocket for certain services when it was cheaper then using insurance, they might actually lose money (or at least not make as much money :happy ).
I'm not sure how Cigna benefits directly from this. It would be the doctor doing better on the lab test charges having you go through insurance. Cigna does benefit in part in that they're presumably able to decrease the margin on the visit cost and increase the margin on the lab work. Whether that works out better for the doctor or not would depend on the actual numbers, but other than Cigna having good rates, I don't see how it benefits them.

There is a very large concern about doctors over-billing patients by not submitting some things through insurance, so I think the rule, if it exists, does make sense, although it may not be particularly beneficial to you.
Made money. Lost money. Learned to stop counting.
Topic Author
paws
Posts: 24
Joined: Sat Dec 02, 2017 9:54 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

Artsdoctor wrote: Mon Apr 24, 2023 7:39 pm If the physician is enrolled in your particular plan, the physician is not allowed to charge a cash price. For example, if I'm (as a physician) enrolled in a Blue Cross network and a patient is seen in my office, I'm obligated to run the visit through the insurance and I must accept the negotiated rate. The patient doesn't really have a say in the matter. Certainly you can imagine that a Medicare provider cannot bill the patient for a cash visit--and the Medicare patient cannot "turn off" her Medicare policy with a physician who's a Medicare provider.

However, if the physician is not part of the plan, the patient can certainly pay the cash balance at the time of the visit.
Thanks, TIL. So if I understand correctly, when a physician 'enrolls in a plan' [unnecessary comment removed - moderator ClaycordJCA] insurance companies get carte blanche intermediation of the patient/provider relationship, even when neither party consents to involve the insurance company?
Presumably the medical professional chooses to sacrifice autonomy presumably because they expect to get some steady supply of patients from the plan. Meanwhile the patient enrolls because even though they can afford occasional doctor visits, they want protection from bankruptcy in case of disaster. But the result is an (IMO) unjust intermediation of two entities that wish to transact directly.

I'm not a medical professional, likely I'm ignorant of context, but wow it sounds rather incredible. I thought America valued the individual and so-called free enterprise. Talk about super villains - when looking at health costs as a % of GDP I find it difficult to see evils worse than the scam US health insurance companies + the AMA have foisted on us 😞

Anyway. What levers exist to work around this situation in future?
Is the physician personally enrolled in the plan by their name? Or is it their practice (i.e. their legal entity?)
I'm curious to see if there's a way a physician can see me in a "different office", otherwise tweak the parameters such that this asinine rule wouldn't apply.

It also occurs to me, providers only know what plan I'm in if I tell them. 🤔
Last edited by paws on Mon Apr 24, 2023 8:43 pm, edited 3 times in total.
ScubaHogg
Posts: 3573
Joined: Sun Nov 06, 2011 2:02 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by ScubaHogg »

paws wrote: Mon Apr 24, 2023 8:32 pm
…even when neither party consents to involve the insurance company.
I’m not a lawyer, but I’m guessing both parties consented under the terms and conditions of the insurance agreement they each signed up for

You are free to change your insurance coverage of course
“Conventional Treasury rates are risk free only in the sense that they guarantee nominal principal. But their real rate of return is uncertain until after the fact.” -Risk Less and Prosper
Topic Author
paws
Posts: 24
Joined: Sat Dec 02, 2017 9:54 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

ScubaHogg wrote: Mon Apr 24, 2023 8:40 pm
paws wrote: Mon Apr 24, 2023 8:32 pm
…even when neither party consents to involve the insurance company.
I’m not a lawyer, but I’m guessing both parties consented under the terms and conditions of the insurance agreement they each signed up for

You are free to change your insurance coverage of course
In this case it sounds like the provider might have agreed, but unless I'm mistaken I'm pretty sure I never did. I'm someone that reads every word of the EULAs and ToS I sign up for, I take screenshots and photographs and make PDFs of everything as much as possible. I could be wrong, but in looking at what I retained I haven't found any evidence I agreed to such a term.

FWIW I used the GetCovered site last year to get enrolled. I seem to recall there was some kind of "eSignature" step for the interview about income/household details, but not a second one afterwards with the actual insurance carrier.
safari
Posts: 651
Joined: Mon Nov 08, 2021 1:23 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by safari »

This doesn't make sense to me. It should be up to the patient to decide whether they want to use the insurance for a specific visit. What if you tell the office that you no longer have insurance?

I have an HDHP, and I only use it for routine services, which are covered 100%, but otherwise I go to an Urgent Care, which doesn't accept any insurance and charges only $75 for a visit. It's super convenient, as I don't have to make an appointment, and it's cheaper than the negotiated rate I'd have to pay to my regular doctor when using insurance. My doctor's cash rate is actually higher than the negotiated insurance rate, so this issue has never come up for me.
User avatar
MrBobcat
Posts: 1292
Joined: Fri Jan 11, 2019 4:19 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by MrBobcat »

paws wrote: Mon Apr 24, 2023 6:42 pm Will appreciate any thoughts, thanks!
Is it possible you'll annoy the dermatologist's office enough that you'll have to find a new dermatologist?
Topic Author
paws
Posts: 24
Joined: Sat Dec 02, 2017 9:54 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

safari wrote: Mon Apr 24, 2023 9:28 pm This doesn't make sense to me. It should be up to the patient to decide whether they want to use the insurance for a specific visit. What if you tell the office that you no longer have insurance?

I have an HDHP, and I only use it for routine services, which are covered 100%, but otherwise I go to an Urgent Care, which doesn't accept any insurance and charges only $75 for a visit. It's super convenient, as I don't have to make an appointment, and it's cheaper than the negotiated rate I'd have to pay to my regular doctor when using insurance. My doctor's cash rate is actually higher than the negotiated insurance rate, so this issue has never come up for me.
I agree it should be up to the patient, but I think telling the office you no longer have insurance is unlikely to work bc
1) the provider scanned my drivers license when I entered
2) the assistant took a photo of my face when I entered the room (was super weird and happened really fast before I could object - was incredibly off-putting. next time it happens I'd take a photo right back)
3) pretty sure providers can look up enrollment status of individual patients on the carrier website
4) the catchall: providers consent to be audited when they enroll in a plan

So unless your name is Bruce Wayne and they accept it, it seems risky.

Out of interest how does your urgent care provider cover dermatology?
Topic Author
paws
Posts: 24
Joined: Sat Dec 02, 2017 9:54 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

MrBobcat wrote: Mon Apr 24, 2023 9:36 pm
paws wrote: Mon Apr 24, 2023 6:42 pm Will appreciate any thoughts, thanks!
Is it possible you'll annoy the dermatologist's office enough that you'll have to find a new dermatologist?
I was pretty unimpressed with the visit, so I likely will go elsewhere actually.

This is my first time using American health care in several years and quite honestly it was the worst professional service experience I've had so far in 2023. To be clear it wasn't because of the actual medical professional, who was reasonably competent in the end.
Rather it's the gauntlet of legalese, insurance company scams, unnecessary middlemen and high costs just to get in the room. From a patient experience perspective, it was awful. At least three other countries I've personally lived in/visited have offered equivalent quality medical treatment without all the [profanity removed - moderator ClaycordJCA]. Knowing there are talented and motivated medical professionals in the US, I find it pretty damning how hard it is to utilize their services, even when I am ready to pay cash on the spot.

I wonder if Americans don't realize how bad things are because they're covered by their employer's health insurance and don't see the ugly underbelly.
Last edited by paws on Mon Apr 24, 2023 10:15 pm, edited 1 time in total.
safari
Posts: 651
Joined: Mon Nov 08, 2021 1:23 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by safari »

paws wrote: Mon Apr 24, 2023 9:45 pm Out of interest how does your urgent care provider cover dermatology?
My urgent care provider is a family doctor who can treat pretty much everything. Last year I had something grow under my skin, causing pain and discomfort. He prescribed me some medicine, which took care of it, so I didn't even have to see a specialist.
Topic Author
paws
Posts: 24
Joined: Sat Dec 02, 2017 9:54 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

safari wrote: Mon Apr 24, 2023 10:15 pm
paws wrote: Mon Apr 24, 2023 9:45 pm Out of interest how does your urgent care provider cover dermatology?
My urgent care provider is a family doctor who can treat pretty much everything. Last year I had something grow under my skin, causing pain and discomfort. He prescribed me some medicine, which took care of it, so I didn't even have to see a specialist.
That's fantastic. My derma need was just for a simple prescription. Sounds like I might be able to come to a similar arrangement, if I find the right family doctor. Thank you, TIL!

I'd be curious on tips for finding a good family doctor :) Word of mouth?
safari
Posts: 651
Joined: Mon Nov 08, 2021 1:23 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by safari »

paws wrote: Mon Apr 24, 2023 10:20 pm
safari wrote: Mon Apr 24, 2023 10:15 pm
paws wrote: Mon Apr 24, 2023 9:45 pm Out of interest how does your urgent care provider cover dermatology?
My urgent care provider is a family doctor who can treat pretty much everything. Last year I had something grow under my skin, causing pain and discomfort. He prescribed me some medicine, which took care of it, so I didn't even have to see a specialist.
That's fantastic. My derma need was just for a simple prescription. Sounds like I might be able to come to a similar arrangement, if I find the right family doctor. Thank you, TIL!

I'd be curious on tips for finding a good family doctor :) Word of mouth?
I found my doctor on Yelp. He has over 500 5-star reviews.
Katietsu
Posts: 7677
Joined: Sun Sep 22, 2013 1:48 am

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Katietsu »

paws wrote: Mon Apr 24, 2023 9:49 pm
MrBobcat wrote: Mon Apr 24, 2023 9:36 pm
paws wrote: Mon Apr 24, 2023 6:42 pm Will appreciate any thoughts, thanks!
Is it possible you'll annoy the dermatologist's office enough that you'll have to find a new dermatologist?
I was pretty unimpressed with the visit, so I likely will go elsewhere actually.

This is my first time using American health care in several years and quite honestly it was the worst professional service experience I've had so far in 2023. To be clear it wasn't because of the actual medical professional, who was reasonably competent in the end.
Rather it's the gauntlet of legalese, insurance company scams, unnecessary middlemen and high costs just to get in the room. From a patient experience perspective, it was awful. At least three other countries I've personally lived in/visited have offered equivalent quality medical treatment without all the BS. Knowing there are talented and motivated medical professionals in the US, I find it pretty damning how hard it is to utilize their services, even when I am ready to pay cash on the spot.

I wonder if Americans don't realize how bad things are because they're covered by their employer's health insurance and don't see the ugly underbelly.
I certainly can not speak for all “Americans” but I know how bad things are as do many American friends and family, including pretty much all the healthcare professionals. If you ever try TikTok, take a look at the videos by DrGlacomflecken. Funny while frightening dramatization of how insurance and physicians interact.
JBTX
Posts: 11227
Joined: Wed Jul 26, 2017 12:46 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by JBTX »

paws wrote: Mon Apr 24, 2023 9:49 pm
MrBobcat wrote: Mon Apr 24, 2023 9:36 pm
paws wrote: Mon Apr 24, 2023 6:42 pm Will appreciate any thoughts, thanks!
Is it possible you'll annoy the dermatologist's office enough that you'll have to find a new dermatologist?
I was pretty unimpressed with the visit, so I likely will go elsewhere actually.

This is my first time using American health care in several years and quite honestly it was the worst professional service experience I've had so far in 2023. To be clear it wasn't because of the actual medical professional, who was reasonably competent in the end.
Rather it's the gauntlet of legalese, insurance company scams, unnecessary middlemen and high costs just to get in the room. From a patient experience perspective, it was awful. At least three other countries I've personally lived in/visited have offered equivalent quality medical treatment without all the BS. Knowing there are talented and motivated medical professionals in the US, I find it pretty damning how hard it is to utilize their services, even when I am ready to pay cash on the spot.

I wonder if Americans don't realize how bad things are because they're covered by their employer's health insurance and don't see the ugly underbelly.
There is a pretty widespread frustration with medical insurance policies. Employer provided medical care here started many decades ago as a way to provide extra employee compensation but at the same time not provide additional monetary compensation. I don’t recall if it was due to price controls, unions, or what, but that’s how it started and it has persisted since. Past that point, you have many vested parties and private interests in the status quo (health insurance companies, hospital networks, pharmacies, drug manufacturers, etc )combined with some people who fear change, and the result is the current system persists, with minor tweaks over time.

To your original post, I suspect the issue is if the provider is “in network”, then there is a contract between the provider and the insurance company, and the provider is obligated to bill the insurance company rate. In most cases that will result in lower patient charges, in exchange for more in network patients coming from the insurance company. But in your case and rare cases a cash price could end up being lower. Even if the cash price is a little lower, it could still be beneficial to go with the network rate, as then the amount you pay will go towards the deductible and out of pocket maximums per the policy.

A similar situation for HDHPs is prescription drugs. In those cases, you can often get lower cash prices via GoodRx or other discount plan compared to insurance negotiated price, and typically with pharmacies you can choose either/or. If you choose the GoodRx price though it won’t go against deductible and out of pocket.
an_asker
Posts: 4903
Joined: Thu Jun 27, 2013 2:15 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by an_asker »

Artsdoctor wrote: Mon Apr 24, 2023 7:39 pm If the physician is enrolled in your particular plan, the physician is not allowed to charge a cash price. For example, if I'm (as a physician) enrolled in a Blue Cross network and a patient is seen in my office, I'm obligated to run the visit through the insurance and I must accept the negotiated rate. The patient doesn't really have a say in the matter. Certainly you can imagine that a Medicare provider cannot bill the patient for a cash visit--and the Medicare patient cannot "turn off" her Medicare policy with a physician who's a Medicare provider.

However, if the physician is not part of the plan, the patient can certainly pay the cash balance at the time of the visit.
As a consumer, I don't like that. What you are saying is that I am obligated to paying the middle man plus the provider just because I am already paying the middle man? If the "negotiated rate" is higher than what a doctor would charge a walk-in no-insurance patient, isn't the insured patient the loser here? :oops:

Why is the patient obligated to share information about his/her plan? Why can't they pay the no-insurance charge (assuming that it is lower) if they so choose?
Texanbybirth
Posts: 1612
Joined: Tue Apr 14, 2015 12:07 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Texanbybirth »

an_asker wrote: Tue Apr 25, 2023 8:00 am
Artsdoctor wrote: Mon Apr 24, 2023 7:39 pm If the physician is enrolled in your particular plan, the physician is not allowed to charge a cash price. For example, if I'm (as a physician) enrolled in a Blue Cross network and a patient is seen in my office, I'm obligated to run the visit through the insurance and I must accept the negotiated rate. The patient doesn't really have a say in the matter. Certainly you can imagine that a Medicare provider cannot bill the patient for a cash visit--and the Medicare patient cannot "turn off" her Medicare policy with a physician who's a Medicare provider.

However, if the physician is not part of the plan, the patient can certainly pay the cash balance at the time of the visit.
As a consumer, I don't like that. What you are saying is that I am obligated to paying the middle man plus the provider just because I am already paying the middle man? If the "negotiated rate" is higher than what a doctor would charge a walk-in no-insurance patient, isn't the insured patient the loser here? :oops:

Why is the patient obligated to share information about his/her plan? Why can't they pay the no-insurance charge (assuming that it is lower) if they so choose?
I think you’re welcome to not put down any insurance information when you visit a doctor, but once you tell them you have insurance they (seemingly) have to use it. Kinda like a realtor: you don’t have to have one to visit a house for sale, but (at least in Texas) once you use a realtor to see a house you’re obligated to use them to close the deal (if you move forward with the house).
“The strong cannot be brave. Only the weak can be brave; and yet again, in practice, only those who can be brave can be trusted, in time of doubt, to be strong.“ - GK Chesterton
Jags4186
Posts: 8198
Joined: Wed Jun 18, 2014 7:12 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Jags4186 »

FWIW I would just go through insurance. Will it cost more? Maybe. The urgent care I go to charges $125 for self pay and $132.60 through insurance. But it counts towards the deductible and in the off chance I do end up in the emergency room and blow through my deductible I'd rather have been building towards it.
hachiko
Posts: 941
Joined: Fri Mar 17, 2017 1:56 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by hachiko »

an_asker wrote: Tue Apr 25, 2023 8:00 am
Artsdoctor wrote: Mon Apr 24, 2023 7:39 pm If the physician is enrolled in your particular plan, the physician is not allowed to charge a cash price. For example, if I'm (as a physician) enrolled in a Blue Cross network and a patient is seen in my office, I'm obligated to run the visit through the insurance and I must accept the negotiated rate. The patient doesn't really have a say in the matter. Certainly you can imagine that a Medicare provider cannot bill the patient for a cash visit--and the Medicare patient cannot "turn off" her Medicare policy with a physician who's a Medicare provider.

However, if the physician is not part of the plan, the patient can certainly pay the cash balance at the time of the visit.
As a consumer, I don't like that. What you are saying is that I am obligated to paying the middle man plus the provider just because I am already paying the middle man? If the "negotiated rate" is higher than what a doctor would charge a walk-in no-insurance patient, isn't the insured patient the loser here? :oops:

Why is the patient obligated to share information about his/her plan? Why can't they pay the no-insurance charge (assuming that it is lower) if they so choose?
The way I see it, if I understand this correctly, is that they are effectively bundling services in different ways to charge different amounts. It's like when you book a vacation through a third party, maybe they charge you $500/night for the room and $50/night for all inclusive food. Perhaps the hotel charges regular guests that book directly through them $450/night for the room and $105/night for all inclusive food. You don't get to pick the $50/night for all inclusive food and the $450/night for the room. You get to choose one bundle or the other. And if all you need is the room, then you'd want to book directly with the hotel. But if what you need is the room and food, you'd book with the third party.
Made money. Lost money. Learned to stop counting.
User avatar
Artful Dodger
Posts: 1952
Joined: Thu Oct 20, 2016 12:56 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Artful Dodger »

I work in the field (employee benefits broker) and I routinely see insurance company / PPO discounts in the 40-50% range with some a lot higher. I've seen Quest and Lab Corp discounts as high as 90%. In cases where patients may not have insurance or they're getting a non-covered service, the most common discount I see is 20-25%. Unless it's something specifically not covered, I'd let the provider bill the insurer. Also, as noted above, if they don't bill, it won't count towards your deductible which you'll want should a larger claim come along later.
User avatar
Artsdoctor
Posts: 6063
Joined: Thu Jun 28, 2012 3:09 pm
Location: Los Angeles, CA

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Artsdoctor »

I think that there might be some misunderstandings. Of course the national medical insurance situation is complex, to say the least.

As a physician, I have a fundamental decision to make regarding insurance: do I enroll in the network or not. I doesn't make any difference if the insurance program is Medicare, Medicaid, PPO, HMO, or other systems. I decide whether or not to enroll in the plan (or, if I'm employed by a healthcare entity, my employer decides whether to enroll).

As a patient, I choose a plan, I have one chosen for me, or I don't have a plan.

If a physician, or a group of physicians, enrolls in any plan, they sign an agreement to abide by the rules of the plan. The plan usually stipulates that you'll agree to the pricing set out by the plan. This is ostensibly for the benefit of the patient in order to avoid over-billing, or "balance billing," the patient although the agreement here is certainly complex and involves multiple reasons to agree to the plan. Nonetheless, if you sign up for the plan, you agree to the plan's terms.

So if a patient comes into the office and is a member of the plan that I'm also a member of, we both abide by the rules of our mutual plan. I can't choose to ignore the plan's rules. The time for that would have been before signing up for the plan in the first place.

There are some plans that attempt to give patients some flexibility on which portion of the plan to use (opting for the HMO component or the PPO component, for example). It's been my experience that the more complex the plan, the more likelihood that errors will occur in billing. Nonetheless, the concept remains that if the physician and the patient belong to the same plan, they need to work within the confines of what the written agreement is.

The best example of all of this is Medicare because it's such a large plan with such a large network of doctors, as well as the sheer quantity of patients belonging to the plan. If the physician is a Medicare provider, meaning they've signed an agreement to provide care to Medicare patients, they must adhere to the rules of Medicare, certainly when it comes to billing. A Medicare patient cannot choose to ignore that they've enrolled in Medicare nor can a physician choose to ignore their enrollment agreement in Medicare.

There are some workarounds--administrative fees, concierge fees, etc., but they can be challenging to work with.

As a physician, if I (or my employer) don't want to sign up for a plan, I don't. Likewise, if you are a patient and you don't want to use your insurance for whatever reason, you go to a provider outside of your plan.
an_asker
Posts: 4903
Joined: Thu Jun 27, 2013 2:15 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by an_asker »

Artsdoctor wrote: Tue Apr 25, 2023 1:00 pm I think that there might be some misunderstandings. Of course the national medical insurance situation is complex, to say the least.
[...]
I get the point you are trying to make.

But that doesn't stop me from feeling cheated (to be very blunt) if a doctor would charge me (who is part of a plan) $100 for something that he/she would charge someone else - especially someone who does not even have a plan - only $75. Because what that tells me is that the doctor had inflated the rate when presenting it to the insurance.

Maybe if I give a non-medical analogy, it would make sense. Let's say you are SAMS member and I am not. You pay $50 for the privilege to be a member. You and I go to SAMS (if you, for now, ignore the fact that SAMS doesn't permit entry to non-members) and when you pay $20 for a T-shirt, you see that I can purchase the same T-shirt for $15. How would you feel? I can make all sorts of arguments that well, fifty other items that SAMS sells would cost you less than they would cost me but ... wouldn't you feel like you got cheated if I pay 25% less for the same product?

To me, what would be fair is that if an uninsured patient is charged at least the most that a doctor would charge an insured patient. In other words,

- blue cross insurance $100
- umr insurance $95
- anthem insurance $105
- cigna insurance $125

... then I think an uninsured patient should be charged at least $125. Anything less and I would say that's unfair!
User avatar
Artsdoctor
Posts: 6063
Joined: Thu Jun 28, 2012 3:09 pm
Location: Los Angeles, CA

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Artsdoctor »

^ I can't speak for other physicians. The price for the office visit, the hospital visit, the procedure, etc., is the same for everyone. If I set the office visit price at $100 and various insurance companies pay me different prices, that's part of the equation you do when you sign up for the plan (if I know one insurer will pay me $95 for the visit and another will pay only $20, I wouldn't sign up for the second insurer's plan). I don't choose my office visit price according to the way you look or what insurance plan you have. If I choose to discount an office visit price, for example due to patient hardship, I can do that. However, the more exceptions you make, the more likely you are to get into some sort of billing hassle that you will have wished you'd avoided.

It's very possible that your initial out-of-pocket expense will be greater staying in your plan. If that's the case, you'd go to a physician that is not part of your plan and you'd pay cash. That's definitely an option for you and I've been on both sides of that equation many times.
User avatar
Artful Dodger
Posts: 1952
Joined: Thu Oct 20, 2016 12:56 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Artful Dodger »

Artsdoctor wrote: Tue Apr 25, 2023 1:00 pm I think that there might be some misunderstandings. Of course the national medical insurance situation is complex, to say the least.

As a physician, I have a fundamental decision to make regarding insurance: do I enroll in the network or not. I doesn't make any difference if the insurance program is Medicare, Medicaid, PPO, HMO, or other systems. I decide whether or not to enroll in the plan (or, if I'm employed by a healthcare entity, my employer decides whether to enroll).

As a patient, I choose a plan, I have one chosen for me, or I don't have a plan.

If a physician, or a group of physicians, enrolls in any plan, they sign an agreement to abide by the rules of the plan. The plan usually stipulates that you'll agree to the pricing set out by the plan. This is ostensibly for the benefit of the patient in order to avoid over-billing, or "balance billing," the patient although the agreement here is certainly complex and involves multiple reasons to agree to the plan. Nonetheless, if you sign up for the plan, you agree to the plan's terms.

So if a patient comes into the office and is a member of the plan that I'm also a member of, we both abide by the rules of our mutual plan. I can't choose to ignore the plan's rules. The time for that would have been before signing up for the plan in the first place.

There are some plans that attempt to give patients some flexibility on which portion of the plan to use (opting for the HMO component or the PPO component, for example). It's been my experience that the more complex the plan, the more likelihood that errors will occur in billing. Nonetheless, the concept remains that if the physician and the patient belong to the same plan, they need to work within the confines of what the written agreement is.

The best example of all of this is Medicare because it's such a large plan with such a large network of doctors, as well as the sheer quantity of patients belonging to the plan. If the physician is a Medicare provider, meaning they've signed an agreement to provide care to Medicare patients, they must adhere to the rules of Medicare, certainly when it comes to billing. A Medicare patient cannot choose to ignore that they've enrolled in Medicare nor can a physician choose to ignore their enrollment agreement in Medicare.

There are some workarounds--administrative fees, concierge fees, etc., but they can be challenging to work with.

As a physician, if I (or my employer) don't want to sign up for a plan, I don't. Likewise, if you are a patient and you don't want to use your insurance for whatever reason, you go to a provider outside of your plan.
Well said!

The main advantage is the protection from balance billing, as you noted, as well as having the provider actually bill the insurance and wait for payment.
an_asker
Posts: 4903
Joined: Thu Jun 27, 2013 2:15 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by an_asker »

Artsdoctor wrote: Tue Apr 25, 2023 1:24 pm ^ I can't speak for other physicians. The price for the office visit, the hospital visit, the procedure, etc., is the same for everyone. If I set the office visit price at $100 and various insurance companies pay me different prices, that's part of the equation you do when you sign up for the plan (if I know one insurer will pay me $95 for the visit and another will pay only $20, I wouldn't sign up for the second insurer's plan). I don't choose my office visit price according to the way you look or what insurance plan you have. If I choose to discount an office visit price, for example due to patient hardship, I can do that. However, the more exceptions you make, the more likely you are to get into some sort of billing hassle that you will have wished you'd avoided.

It's very possible that your initial out-of-pocket expense will be greater staying in your plan. If that's the case, you'd go to a physician that is not part of your plan and you'd pay cash. That's definitely an option for you and I've been on both sides of that equation many times.
Based on the above, yours appears to be a fair practice (not that I am judging lol). And if I were in your shoes, I would do the same (re: rejecting the second insurer as that wouldn't be fair to me).

What makes/made me upset is what OP appears to be talking about, where it appears that the cost to an uninsured is lower than what it is to the insured (i.e., OP).
User avatar
Artful Dodger
Posts: 1952
Joined: Thu Oct 20, 2016 12:56 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Artful Dodger »

an_asker wrote: Tue Apr 25, 2023 1:12 pm To me, what would be fair is that if an uninsured patient is charged at least the most that a doctor would charge an insured patient. In other words,

- blue cross insurance $100
- umr insurance $95
- anthem insurance $105
- cigna insurance $125

... then I think an uninsured patient should be charged at least $125. Anything less and I would say that's unfair!
In actual practice, the doctor charges everyone the same amount. What people pay depends on their insurance. So for the above example, we'll assume the doctor's charge is $175.

Assuming the accept Medicaid, the doctor gets $65
If Medicare, they get $75
If BCBS, they get $115
If, Aetna, UHC, Cigna, they get between $115 and $140

There are plenty of other variables in play. Some insurers have deeper discounts on some services, less on others. Some don't allow certain services to be bundled and will deny certain services and tell the provider that they can't balance bill the member, and so on.

If the patient is uninsured, they're billed the same $175 rate. If they don't check beforehand, they may not get any discount, or may get some type of quick pay discount. If they try to negotiate something beforehand, and the office has a regular policy, it's most often a 20-25% discount, so the doctor gets $125 to $175. There can certainly be variations, but this is what I see most often.

That's not to say the provider (especially an institution or group) may offer a charity / needs-based discount.

I've been involved in a number of negotiations throughout the years, and I find there is less flexibility now than in the past.
User avatar
Artful Dodger
Posts: 1952
Joined: Thu Oct 20, 2016 12:56 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Artful Dodger »

an_asker wrote: Tue Apr 25, 2023 1:42 pm
Artsdoctor wrote: Tue Apr 25, 2023 1:24 pm ^ I can't speak for other physicians. The price for the office visit, the hospital visit, the procedure, etc., is the same for everyone. If I set the office visit price at $100 and various insurance companies pay me different prices, that's part of the equation you do when you sign up for the plan (if I know one insurer will pay me $95 for the visit and another will pay only $20, I wouldn't sign up for the second insurer's plan). I don't choose my office visit price according to the way you look or what insurance plan you have. If I choose to discount an office visit price, for example due to patient hardship, I can do that. However, the more exceptions you make, the more likely you are to get into some sort of billing hassle that you will have wished you'd avoided.

It's very possible that your initial out-of-pocket expense will be greater staying in your plan. If that's the case, you'd go to a physician that is not part of your plan and you'd pay cash. That's definitely an option for you and I've been on both sides of that equation many times.
Based on the above, yours appears to be a fair practice (not that I am judging lol). And if I were in your shoes, I would do the same (re: rejecting the second insurer as that wouldn't be fair to me).

What makes/made me upset is what OP appears to be talking about, where it appears that the cost to an uninsured is lower than what it is to the insured (i.e., OP).
If you reread the first post, the OP says he was never told what the insurance company would pay. He only reported an estimated cost if paid in cash.
"When I called ahead to inquire about my derma visit, she said self-pay cash price was $200-250, but she wouldn't/couldn't say the insurance side."
Topic Author
paws
Posts: 24
Joined: Sat Dec 02, 2017 9:54 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

an_asker wrote: Tue Apr 25, 2023 1:42 pm What makes/made me upset is what OP appears to be talking about, where it appears that the cost to an uninsured is lower than what it is to the insured (i.e., OP).
I'm still learning in this world, but yes, that was one of the assumptions I made when deciding to try an HDHP plan this year. (i.e. "avoid middlemen to lower costs"). Based on this experience, what insurance pays a provider is not necessarily easy to learn ahead of time. If anyone is interested I'll be happy to post back when I get the EOB and bill from insurance side.

Separate from outpatient/specialist visits but thought I'd share - as part of my learning on this I reviewed a few local so-called "chargemasters." You might know as of 1/2021 hospitals are required to publicly post theirs by law (although apparently compliance hasn't been too great).

So I got curious and downloaded the UPenn chargemaster, and scrolled to the first procedure which happens to be heart transplants.

I learned there is a "Charge/cash price" as well as an "Uninsured" rate that is lower than some, but not all, of the contracted carrier rates
Transposing the cells makes it a lot easier to read, I include it here:
https://imgur.com/a/BdBWJfy

The skew here is pretty dramatic - looks like "UnitedHealthCare Options and OneNet" members pay $31k, but "First Health" will pay $1.29m. I don't understand why any heart surgeon would enroll in a UnitedHealthCare Options and OneNet plan. 🤷

If anyone works in medical billing or has insight to share I'll be most appreciative.
Topic Author
paws
Posts: 24
Joined: Sat Dec 02, 2017 9:54 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

Artful Dodger wrote: Tue Apr 25, 2023 2:02 pm
an_asker wrote: Tue Apr 25, 2023 1:12 pm To me, what would be fair is that if an uninsured patient is charged at least the most that a doctor would charge an insured patient. In other words,

- blue cross insurance $100
- umr insurance $95
- anthem insurance $105
- cigna insurance $125

... then I think an uninsured patient should be charged at least $125. Anything less and I would say that's unfair!
In actual practice, the doctor charges everyone the same amount. What people pay depends on their insurance. So for the above example, we'll assume the doctor's charge is $175.

Assuming the accept Medicaid, the doctor gets $65
If Medicare, they get $75
If BCBS, they get $115
If, Aetna, UHC, Cigna, they get between $115 and $140

There are plenty of other variables in play. Some insurers have deeper discounts on some services, less on others. Some don't allow certain services to be bundled and will deny certain services and tell the provider that they can't balance bill the member, and so on.

If the patient is uninsured, they're billed the same $175 rate. If they don't check beforehand, they may not get any discount, or may get some type of quick pay discount. If they try to negotiate something beforehand, and the office has a regular policy, it's most often a 20-25% discount, so the doctor gets $125 to $175. There can certainly be variations, but this is what I see most often.

That's not to say the provider (especially an institution or group) may offer a charity / needs-based discount.

I've been involved in a number of negotiations throughout the years, and I find there is less flexibility now than in the past.
@ArtfulDodger do I understand you right, the doctor performs whatever service, and sends their invoice, and everyone gets charged the same amount.
But the money the doctor actually gets paid is less than their invoice? Why? I'm not aware of any other context in which that would be legal. If you could explain why it works like that I'd be obliged.
Last edited by paws on Tue Apr 25, 2023 3:15 pm, edited 1 time in total.
Random Poster
Posts: 3314
Joined: Wed Feb 03, 2010 9:17 am

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Random Poster »

paws wrote: Tue Apr 25, 2023 3:03 pm Based on this experience, what insurance pays a provider is not necessarily easy to learn ahead of time.
It is, essentially, impossible to find out this information at any time prior to actually receiving a bill from the provider.

And that makes it extremely difficult to determine which insurance company to go with during open enrollment on the ACA exchange.

Because if Company 1’s plan says “you pay 20% coinsurance,” but Company 2’s plan says “you pay 30% coinsurance,” how do you know which is the better deal for you without knowing what Company 1 and Company 2 contracted rates are?

Yet neither Company will tell you that information.

It is beyond maddening.
Most experiences are better imagined.
hkcj
Posts: 151
Joined: Wed Dec 21, 2016 1:53 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by hkcj »

Random Poster wrote: Tue Apr 25, 2023 3:15 pm
paws wrote: Tue Apr 25, 2023 3:03 pm Based on this experience, what insurance pays a provider is not necessarily easy to learn ahead of time.
It is, essentially, impossible to find out this information at any time prior to actually receiving a bill from the provider.

And that makes it extremely difficult to determine which insurance company to go with during open enrollment on the ACA exchange.

Because if Company 1’s plan says “you pay 20% coinsurance,” but Company 2’s plan says “you pay 30% coinsurance,” how do you know which is the better deal for you without knowing what Company 1 and Company 2 contracted rates are?

Yet neither Company will tell you that information.

It is beyond maddening.
Insurance companies must post this data now. Of course the datasets are huge but some companies are working to analyze it if I recall correctly.
User avatar
Artful Dodger
Posts: 1952
Joined: Thu Oct 20, 2016 12:56 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Artful Dodger »

paws wrote: Tue Apr 25, 2023 3:12 pm
Artful Dodger wrote: Tue Apr 25, 2023 2:02 pm
an_asker wrote: Tue Apr 25, 2023 1:12 pm To me, what would be fair is that if an uninsured patient is charged at least the most that a doctor would charge an insured patient. In other words,

- blue cross insurance $100
- umr insurance $95
- anthem insurance $105
- cigna insurance $125

... then I think an uninsured patient should be charged at least $125. Anything less and I would say that's unfair!
In actual practice, the doctor charges everyone the same amount. What people pay depends on their insurance. So for the above example, we'll assume the doctor's charge is $175.

Assuming the accept Medicaid, the doctor gets $65
If Medicare, they get $75
If BCBS, they get $115
If, Aetna, UHC, Cigna, they get between $115 and $140

There are plenty of other variables in play. Some insurers have deeper discounts on some services, less on others. Some don't allow certain services to be bundled and will deny certain services and tell the provider that they can't balance bill the member, and so on.

If the patient is uninsured, they're billed the same $175 rate. If they don't check beforehand, they may not get any discount, or may get some type of quick pay discount. If they try to negotiate something beforehand, and the office has a regular policy, it's most often a 20-25% discount, so the doctor gets $125 to $175. There can certainly be variations, but this is what I see most often.

That's not to say the provider (especially an institution or group) may offer a charity / needs-based discount.

I've been involved in a number of negotiations throughout the years, and I find there is less flexibility now than in the past.
@ArtfulDodger do I understand you right, the doctor performs whatever service, and sends their invoice, and everyone gets charged the same amount.
But the money the doctor actually gets paid is less than their invoice? Why? I'm not aware of any other context in which that would be legal. If you could explain why it works like that I'd be obliged.

Most plans nowadays are PPO / EPO / HMO - POS, and you also have Medicare and various Medicaid arrangements. Doctors choose to participate in all or some of the plans/networks. I don't know how Medicare and some of the Medicaid plans contract, but within the PPO/EPO networks, providers agree to a price schedule for the various services they offer. The $175 charge I gave above is an example, but in general, that's how the reimbursements work. Usually Medicare / Medicaid are discounted more than commercial payers. You, as a member of BCBS or UHC or whoever, will seek services from a provider in your network, provide your insurer ID, they will bill the insurer who will reprice the claim based upon their contract. What they pay is a function of the contract allowance and your specific benefit plan. In a HDHP plan, they may not pay anything. In the above example, say you have BCBS, BCBS will notify the provider there is a $60 discount, and the provider is allowed to bill you the $115. If there is a traditional plan with a $50 copay, the provider collects $50 from you, they are paid $65 by BCBS, and that's it. The $60 is written off and the provider by contract cannot bill you for the balance.

Explaining why is the hard part. I think it has just evolved over time. Theoretically providers can bill whatever they want, but people want some protection from balance billing. $50 or $100 may not make much difference, but I've seen situations where people have gone out of network and the doctors billing thousands of dollars over what a contracted doctor would have been paid. The insurance companies want broad networks to make their plans easier to sell so in most cases they pay enough to get most providers. The providers know they need to participate in certain networks in order to get a critical mass of customers / patients. They can't, except in very few instances, make it without participating.

I'll be interested in finding out what your EOB says, how much discount you received, and how that compared to the cash pay estimate you were quoted.
DoubleComma
Posts: 2066
Joined: Sun Aug 23, 2020 2:23 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by DoubleComma »

This is a fascinating topic to me. US Healthcare and Health Insurance are an exceptionally complicated system. I see exactly why OP is trying to figure this out, especially if one has a HDHP.

When HDHP and HSA became common I tried to dive into it and figure out if that is where I should be. The HSA was really the attractive element for me since it opened more tax differed space, but in CA tax code has made HSA less attractive so we stick with our PPO plan.

That said, we have to designate a plan choice each year. I've given up on trying to "arbitrage" health insurance in a low consumption year and instead look at the total out of pocket potential on a high consumption year. We simply add up the cost of premium, deductible and co-insurance/out of pocket maximum and chose a plan on that analysis. Most years we never reach the max and when we do its still pretty reasonable overall.
Random Poster
Posts: 3314
Joined: Wed Feb 03, 2010 9:17 am

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by Random Poster »

hkcj wrote: Tue Apr 25, 2023 3:22 pm
Random Poster wrote: Tue Apr 25, 2023 3:15 pm
paws wrote: Tue Apr 25, 2023 3:03 pm Based on this experience, what insurance pays a provider is not necessarily easy to learn ahead of time.
It is, essentially, impossible to find out this information at any time prior to actually receiving a bill from the provider.

And that makes it extremely difficult to determine which insurance company to go with during open enrollment on the ACA exchange.

Because if Company 1’s plan says “you pay 20% coinsurance,” but Company 2’s plan says “you pay 30% coinsurance,” how do you know which is the better deal for you without knowing what Company 1 and Company 2 contracted rates are?

Yet neither Company will tell you that information.

It is beyond maddening.
Insurance companies must post this data now. Of course the datasets are huge but some companies are working to analyze it if I recall correctly.
Well, they might be, but, at least in my case, I can’t access that data without being a member of the insurer’s plan (which goes to my point about how do you find that information during open enrollment when you are specifically trying to decide which insurer’s plan you want to join) and—once you have joined an insurer—the data provided isn’t even useable.

To wit: my own health insurer states the following regarding such data: “ These files are publicly available, but are not necessary intended for member or provider use or interpretation.”

What does that even mean other than “here’s a bunch of data, but you likely won’t be able to interpret any of it.”???
Most experiences are better imagined.
safari
Posts: 651
Joined: Mon Nov 08, 2021 1:23 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by safari »

I have a crazy story about health insurance. Years ago my wife had to do some lab testing, which was really expensive (don't recall the exact cost, but let's say $10K). We were on a high deductible plan. The doctor who referred her to the lab said not to worry though, as the lab would only charge her $100 max out of pocket. She did the tests, the lab submitted a claim to her insurance for $10K, which didn't pay anything, as the lab was out of network and my wife hasn't met her out of network deductible yet. The explanation of benefits said that my wife owed $10K to the lab. We were worried that the lab would send her a bill for $10K, but they only asked her to pay $100 and the rest was written off. However, as far the insurance was concerned, they counted the $10K paid toward the out of network deductible and out of pocket maximum. A few months later my wife had to run the same tests again. The lab submitted a claim for $10K to her insurance again, but this time because she had met the out of network deductible, they paid some percentage of the bill and sent my wife a check for $3K+. The lab then asked my wife to sign the check over to them and the remaining balance was written off. For the rest of that year we enjoyed free health care because we reached the out of pocket maximum, even though, in reality, we only paid $100 out of pocket.
rkhusky
Posts: 17764
Joined: Thu Aug 18, 2011 8:09 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by rkhusky »

paws wrote: Tue Apr 25, 2023 3:12 pm
@ArtfulDodger do I understand you right, the doctor performs whatever service, and sends their invoice, and everyone gets charged the same amount.
But the money the doctor actually gets paid is less than their invoice? Why? I'm not aware of any other context in which that would be legal. If you could explain why it works like that I'd be obliged.
That’s the way it works. Reading off one of my recent EOB’s:
Submitted Charge = $20.00
Plan Allowance = $3.00
Insurance Paid = $3.00
Patient Owes = $0.00

Submitted Charge = $210.00
Plan Allowance = $104.22
Copay = $30.00
Insurance Paid = $74.22
Patient Owes = $30.00
Topic Author
paws
Posts: 24
Joined: Sat Dec 02, 2017 9:54 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

hkcj wrote: Tue Apr 25, 2023 3:22 pm Insurance companies must post this data now. Of course the datasets are huge but some companies are working to analyze it if I recall correctly.
TIL! Thank you, what great news.
I found a CMS page which mentions:
If you’re not able to easily find a plan’s machine-readable file on the plan’s website, we recommend that you use an internet-based search engine and search for key words associated with the required disclosures, including (but not limited to) “machine readable files,” “transparency in coverage,” “in- network rates,” and “out-of-network allowed amounts,” along with the plan’s or issuer’s name.
Mildly amusing how CMS teaches us Google-fu without saying "Google."
Anyway it was enough to guide me to this page which in the footer, they link out to https://horizonblue.sapphiremrfhub.com/
and this page finally yielded me a bunch of JSON files for my plan.

I intend to try and understand it, at least until my patience runs out. 🤞
Topic Author
paws
Posts: 24
Joined: Sat Dec 02, 2017 9:54 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

Random Poster wrote: Tue Apr 25, 2023 4:12 pm Well, they might be, but, at least in my case, I can’t access that data without being a member of the insurer’s plan (which goes to my point about how do you find that information during open enrollment when you are specifically trying to decide which insurer’s plan you want to join) and—once you have joined an insurer—the data provided isn’t even useable.

To wit: my own health insurer states the following regarding such data: “ These files are publicly available, but are not necessary intended for member or provider use or interpretation.”

What does that even mean other than “here’s a bunch of data, but you likely won’t be able to interpret any of it.”???
I hear you @Random Poster. In my case I was able to download the data anonymously.
It's still surprising that providers can't just "ask the insurance company" what the costs of a procedure would be ahead of time. The more I learn the more sophisticated the insurance company racket appears, e.g. guaranteed payments from the federal government, state governments, and as I learned in this thread "prior restraint" against patients/providers who wish to transact directly. It smells like regulatory capture in a big way.

Sidenote, in case you're interested I found a fascinating article about the role the AMA plays in modern medicine. Assuming it's credible it has permanently changed how I regard the AMA. Don't miss the Milton Friedman anecdote in the comments.
toddthebod
Posts: 5737
Joined: Wed May 18, 2022 12:42 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by toddthebod »

paws wrote: Tue Apr 25, 2023 9:25 pm It's still surprising that providers can't just "ask the insurance company" what the costs of a procedure would be ahead of time.
They don't want patients coming back saying, "you said it would only cost $100!"
Topic Author
paws
Posts: 24
Joined: Sat Dec 02, 2017 9:54 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

toddthebod wrote: Tue Apr 25, 2023 10:30 pm
paws wrote: Tue Apr 25, 2023 9:25 pm It's still surprising that providers can't just "ask the insurance company" what the costs of a procedure would be ahead of time.
They don't want patients coming back saying, "you said it would only cost $100!"
I recently learned a bit of good news on this front: another new rule requires to providers to provide patients a "Good Faith Estimate" on request. This means patients can now get in writing, ahead of time, the estimated costs for treatment. Pretty amazing.
https://www.cms.gov/nosurprises/consume ... in-advance

There is a major caveat however, which is that it only applies to self-payers. Rather a conspicuous limitation...I wonder if it's more regulatory capture
hkcj
Posts: 151
Joined: Wed Dec 21, 2016 1:53 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by hkcj »

Random Poster wrote: Tue Apr 25, 2023 4:12 pm
hkcj wrote: Tue Apr 25, 2023 3:22 pm
Random Poster wrote: Tue Apr 25, 2023 3:15 pm
paws wrote: Tue Apr 25, 2023 3:03 pm Based on this experience, what insurance pays a provider is not necessarily easy to learn ahead of time.
It is, essentially, impossible to find out this information at any time prior to actually receiving a bill from the provider.

And that makes it extremely difficult to determine which insurance company to go with during open enrollment on the ACA exchange.

Because if Company 1’s plan says “you pay 20% coinsurance,” but Company 2’s plan says “you pay 30% coinsurance,” how do you know which is the better deal for you without knowing what Company 1 and Company 2 contracted rates are?

Yet neither Company will tell you that information.

It is beyond maddening.
Insurance companies must post this data now. Of course the datasets are huge but some companies are working to analyze it if I recall correctly.
Well, they might be, but, at least in my case, I can’t access that data without being a member of the insurer’s plan (which goes to my point about how do you find that information during open enrollment when you are specifically trying to decide which insurer’s plan you want to join) and—once you have joined an insurer—the data provided isn’t even useable.

To wit: my own health insurer states the following regarding such data: “ These files are publicly available, but are not necessary intended for member or provider use or interpretation.”

What does that even mean other than “here’s a bunch of data, but you likely won’t be able to interpret any of it.”???
It's required to be public, but it's true they aren't directly usable without specific data analysis skills. However: hopefully the market will solve this for us, and businesses will spring up with estimates.

Hospitals have been required to post this data for longer and I did find it usable (if complicated). The remaining problem, I think, is that there isn't a bundled charge. They charge you for this, that, and the other thing, and you have no idea of estimating what those are.
paws wrote: Tue Apr 25, 2023 10:48 pm
toddthebod wrote: Tue Apr 25, 2023 10:30 pm
paws wrote: Tue Apr 25, 2023 9:25 pm It's still surprising that providers can't just "ask the insurance company" what the costs of a procedure would be ahead of time.
They don't want patients coming back saying, "you said it would only cost $100!"
I recently learned a bit of good news on this front: another new rule requires to providers to provide patients a "Good Faith Estimate" on request. This means patients can now get in writing, ahead of time, the estimated costs for treatment. Pretty amazing.
https://www.cms.gov/nosurprises/consume ... in-advance

There is a major caveat however, which is that it only applies to self-payers. Rather a conspicuous limitation...I wonder if it's more regulatory capture
I wonder how much these would correlate to each provider's relative costs via insurance. (Would they at least be in the same order??)
an_asker
Posts: 4903
Joined: Thu Jun 27, 2013 2:15 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by an_asker »

safari wrote: Tue Apr 25, 2023 6:13 pm I have a crazy story about health insurance. Years ago my wife had to do some lab testing, which was really expensive (don't recall the exact cost, but let's say $10K). We were on a high deductible plan. The doctor who referred her to the lab said not to worry though, as the lab would only charge her $100 max out of pocket. She did the tests, the lab submitted a claim to her insurance for $10K, which didn't pay anything, as the lab was out of network and my wife hasn't met her out of network deductible yet. The explanation of benefits said that my wife owed $10K to the lab. We were worried that the lab would send her a bill for $10K, but they only asked her to pay $100 and the rest was written off. However, as far the insurance was concerned, they counted the $10K paid toward the out of network deductible and out of pocket maximum. A few months later my wife had to run the same tests again. The lab submitted a claim for $10K to her insurance again, but this time because she had met the out of network deductible, they paid some percentage of the bill and sent my wife a check for $3K+. The lab then asked my wife to sign the check over to them and the remaining balance was written off. For the rest of that year we enjoyed free health care because we reached the out of pocket maximum, even though, in reality, we only paid $100 out of pocket.
What's crazy is that the lab is allowed to even bill that outrageous amount ... especially if they are satisfied with $100. And them then getting $3000 to me sounds like a (perfectly above board) racket!!
humblecoder
Posts: 1531
Joined: Thu Aug 06, 2020 8:46 am

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by humblecoder »

If someone already brought up this point, I apologize. I didn't see anyone mention it, but I could have missed something.

From the insurance company's point of view, I can kind of see why they would include this language in their in-network agreement.

If the patient self-pays, then obviously the provider should not submit the claim to the insurance company. However, I would imagine that it is possible for a provider to still submit the claim (either accidentally or fraudulently). If the provider does that, they are essentially double dipping.

I would imagine that by adding this language, it would prevent the accidental double billing. Even if the provider is completely 100% ethical, I would surmise that the administrative logistic of keeping track of who self-paid and who didn't is not trivial. By just removing this as an option, it closes that door.

Obviously, intentional fraud isn't prevented from a legal piece of paper.

The above is purely speculative on my part, since I don't work in this area.
an_asker
Posts: 4903
Joined: Thu Jun 27, 2013 2:15 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by an_asker »

Random Poster wrote: Tue Apr 25, 2023 3:15 pm
paws wrote: Tue Apr 25, 2023 3:03 pm Based on this experience, what insurance pays a provider is not necessarily easy to learn ahead of time.
It is, essentially, impossible to find out this information at any time prior to actually receiving a bill from the provider.

And that makes it extremely difficult to determine which insurance company to go with during open enrollment on the ACA exchange.

Because if Company 1’s plan says “you pay 20% coinsurance,” but Company 2’s plan says “you pay 30% coinsurance,” how do you know which is the better deal for you without knowing what Company 1 and Company 2 contracted rates are?

Yet neither Company will tell you that information.

It is beyond maddening.
There is one more thing. Let's say your HMO office visit co-pay is $40. You can go to the provider, talk about whatever issue you want to, and you will end up paying the $40 co-pay.

If you are on an HDHP, the doctor has the leeway to tack on additional charges - let's say you complain to the PCP that you head hurts (issue #1), your back hurts (issue #2), you have a cough (issue #3), the doctor has the freedom to bill three different billing codes. And it being HDHP, you'll pay more than you would if you had presented with just one issue. This is what I hate about insurance and how the system can be (for lack of a better word) gamed. I doubt if the doctor would present all three issues to the insurance if it were an HMO - and even if he/she did, I doubt if the insurance payment would be any higher.
Topic Author
paws
Posts: 24
Joined: Sat Dec 02, 2017 9:54 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

humblecoder wrote: Wed Apr 26, 2023 9:36 am If someone already brought up this point, I apologize. I didn't see anyone mention it, but I could have missed something.

From the insurance company's point of view, I can kind of see why they would include this language in their in-network agreement.

If the patient self-pays, then obviously the provider should not submit the claim to the insurance company. However, I would imagine that it is possible for a provider to still submit the claim (either accidentally or fraudulently). If the provider does that, they are essentially double dipping.

I would imagine that by adding this language, it would prevent the accidental double billing. Even if the provider is completely 100% ethical, I would surmise that the administrative logistic of keeping track of who self-paid and who didn't is not trivial. By just removing this as an option, it closes that door.

Obviously, intentional fraud isn't prevented from a legal piece of paper.

The above is purely speculative on my part, since I don't work in this area.
Respectfully, I find this argument hard to buy. If "accidental" double billing is possible for any business, there is a huge problem. If the billing system makes it difficult for any provider to issue bills correctly, pretty sure they're using the wrong billing system. Also if a patient self-pays and doesn't tell the provider they're in-network, then presumably the provider wouldn't bill the insurance anyway, right?

This has got me considering the "audit" power insurance carriers presumably require (force) when providers enroll in a plan. I would appreciate seeing a sample contract a provider signs. Specifically I'm curious if the carrier has the power to audit "all" of a provider's patient records, vs just the records of "in-network" patients. I would hope HIPAA prevents full access, but not 100% sure.

Basically, I'm trying to think of ways a patient and provider who are in the same plan can transact directly without going through the plan and without putting either party at risk.
humblecoder
Posts: 1531
Joined: Thu Aug 06, 2020 8:46 am

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by humblecoder »

paws wrote: Wed Apr 26, 2023 12:54 pm
humblecoder wrote: Wed Apr 26, 2023 9:36 am If someone already brought up this point, I apologize. I didn't see anyone mention it, but I could have missed something.

From the insurance company's point of view, I can kind of see why they would include this language in their in-network agreement.

If the patient self-pays, then obviously the provider should not submit the claim to the insurance company. However, I would imagine that it is possible for a provider to still submit the claim (either accidentally or fraudulently). If the provider does that, they are essentially double dipping.

I would imagine that by adding this language, it would prevent the accidental double billing. Even if the provider is completely 100% ethical, I would surmise that the administrative logistic of keeping track of who self-paid and who didn't is not trivial. By just removing this as an option, it closes that door.

Obviously, intentional fraud isn't prevented from a legal piece of paper.

The above is purely speculative on my part, since I don't work in this area.
Respectfully, I find this argument hard to buy. If "accidental" double billing is possible for any business, there is a huge problem. If the billing system makes it difficult for any provider to issue bills correctly, pretty sure they're using the wrong billing system. Also if a patient self-pays and doesn't tell the provider they're in-network, then presumably the provider wouldn't bill the insurance anyway, right?

This has got me considering the "audit" power insurance carriers presumably require (force) when providers enroll in a plan. I would appreciate seeing a sample contract a provider signs. Specifically I'm curious if the carrier has the power to audit "all" of a provider's patient records, vs just the records of "in-network" patients. I would hope HIPAA prevents full access, but not 100% sure.

Basically, I'm trying to think of ways a patient and provider who are in the same plan can transact directly without going through the plan and without putting either party at risk.
I didn't mean it as an argument. I thought I had sufficiently caveat to say that it was pure speculation on my part. I fully acknowledge that it can be completely wrong. My thought process was that, while you would HOPE that there would be processes in place to prevent this on the provider side, any administrative process is subject to imperfection, especially when it is designed by people who are by nature imperfect. But perhaps I am not giving medical billing people enough credit :-)
Topic Author
paws
Posts: 24
Joined: Sat Dec 02, 2017 9:54 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by paws »

Artful Dodger wrote: Tue Apr 25, 2023 4:01 pm I'll be interested in finding out what your EOB says, how much discount you received, and how that compared to the cash pay estimate you were quoted.
I received the EOB and bill and am here to update you.

As a quick recap, I previously:
1) called the provider ahead of the visit and was estimated a $200-250 cash price
2) asked the office admin immediately after my visit while still in the office. She looked at her computer and said the charge would be (I think) ~$210. I no longer recall the exact amount, sorry, but I remember it was unsurprising vis a vis the phone estimate.

Today horizonblue.com tells me (* edited to hopefully not doxx myself):

Image

A mystery $325 appears.

Image


A $122.37 discrepancy. Where did that come from?

Let's look at the provider's bill.
Image

Each line item has an identical 9 character prefix, no idea if it's sensitive so I snipped but if you're interested please DM me. The part I left, 99204, appears to be the CPT "Under New Patient" procedure code.

While I didn't bring a stopwatch to my visit (feels like I should next time) I recall it being closer to 10 minutes, 15 tops. It was a routine visit to get a doxy prescription, no tools, no lights/lenses/taking pictures, just talking. The time with the provider was nowhere near 45-59 mins. Why was it billed that way?

EDIT: I'm also curious about this $122.37 "adjustment" on the last line of the bill. @Artful Dodger Is this what you mean when you say the doctor submits a bill and the insurance company doesn't pay the full amount?

I find this all terribly opaque and resent being forced into such an ugly and complicated "system" that seems to benefit middlemen, whom have seemingly no relationship on patient outcomes.
toddthebod
Posts: 5737
Joined: Wed May 18, 2022 12:42 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by toddthebod »

paws wrote: Wed May 31, 2023 2:50 pm While I didn't bring a stopwatch to my visit (feels like I should next time) I recall it being closer to 10 minutes, 15 tops. It was a routine visit to get a doxy prescription, no tools, no lights/lenses/taking pictures, just talking. The time with the provider was nowhere near 45-59 mins. Why was it billed that way?
They are allowed to bill based on the entire time spent on you that day, including charting, reviewing records, etc.
jeam3131
Posts: 268
Joined: Sun Aug 26, 2018 2:48 pm

Re: Are HDHP policyholders actually "disallowed" from self-paying?

Post by jeam3131 »

Billing can be done based on time OR complexity. The complexity definitions are put forth my CMS (medicare), which all insurances follow.

Most of the time, visits will be billed based on complexity, not time.

Even though your EOB lists time, that's all computer programming.

The $ amount your doctor submits to your insurance is largely irrelevant. The insurance only allows the contracted rate. That's why you're seeing an adjustment. No one's paying that money. The bill is just being reduced.

Might be worthwhile to watch some YouTube videos to understand the process.
Post Reply