Can a doctor’s office refuse to see a patient because they don’t accept their insurance?

[acrylic]

@manzanopeek Yeah there are absolutely doctors in my network that won’t accept new patients. Probably 30% of the specialists. Is this wrong? My appt for my allergist is 4 months out. If he had to see every eligible patient how would he meet the needs of the patients he already has? I’m not saying it’s a desirable situation but every doctor can’t see every patient.

 

[waiarlap]

@allaneparker

They told her that it would be insurance fraud to let her self-pay. How is it insurance fraud to have the patient pay for it if no claim is submitted to the insurance?

As others have mentioned, self-pay itself is not fraud, but what they probably meant is that it would be fraud if she reported she didn't have insurance when she did in order to access the provider's self-pay rates. It may seem like a white lie like some others in this thread have suggested, but it's fraud.

If the provider has a contract with an insurance company then they likely have a contractual obligation to run claims for anyone insured by that company through that company rather than billing the insured directly. This makes sense in most cases because you don't want providers skipping the insurance company and billing clients directly when they could be getting benefits under their plan.

And is a doctor’s office allowed to refuse a patient for being self-pay?

Yes for reasons many others have mentioned in this thread.

 

[mountaintrip98]

@allaneparker I'm guessing the "insurance fraud" contract was either a misunderstanding with contractual obligations with in-network insurance or just a lie to get her to go away.

But to answer your question, aside from doctors performing an initial evaluation in an emergency room setting, out-of-network doctors arent' under a legal obligation to provide you with services any more than McDonald's is obligated to provide you hamburgers. And since they're out-of-network they have no contract with the insurance company so there is no recourse through the insurance company.

The blunt fact is she will need to decide if the "many reasons" she's not seeing an in-network doctor are really that important compared with getting her medication, or else find another doctor that will accept her as a self-pay patient.

 

[megano]

@allaneparker The dr is not obligated to do business with anyone, and its common for Dr's to refuse to see patients who don't have a back up form of payment if anything major happens. Some Urgent Cares also schedule people for regular visits, and things like CVS minute clinic, might be better options.

Sounds like the clerk may not have had the best grasp of the ins and outs, and didn't have best vocabulary. Some insurances do have exclusions like this built in, even if itnhas no bearing on this exact case.

 

[av3nger]

@allaneparker In America, most practices are private. Yes, a private business can refuse customers.

 

[newvision2010]

@allaneparker It makes no sense to buck the system. You have insurance, work with the network. Bad network? Change insurance. As far as the doc, they have the right to set parameters for their practice.

 

[leerain]

@newvision2010 Change insurance == change employer. Easy Peasy.

 

[manzanopeek]

@allaneparker Providers can pick and choose which patients they see by insurance and payment method. It is one of the real downsides to the US system. It is why the first question you get asked when calling around to providers is what insurance do you have.

Many providers don't want self-pay for many reasons. billing is hard enough, but trying to figure out cost pre-visit is impossible. and if a provider farms out billing then they usually want nothing to do with self-pay.

The insurance fraud. probably just don't want self-pay, because depending on the insurance it can be fraud. so they just tell everyone the same line to make it easier on their employees. no mistakes can be made when you can train employees that we don't take any self-pay patients with insurance.

If the provider was leaving the practice they should have given ample notice so patients can find a new provider, continuity of care.