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

[allaneparker]

A family member of mine has insurance, but for many reasons does not see an in-network doctor. The plan has limited coverage for out-of-network doctors. She’s been seeing her primary for many years now, and the doctor recently moved to a different group practice. My family member transferred all her patient records and everything, but when she went to set up an appointment they refused to even schedule her because they didn’t accept her insurance. She explained that she’s willing to self pay if needed, but she’s almost out of her medications so she really needs to see the doctor. 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? And is a doctor’s office allowed to refuse a patient for being self-pay?

 

[logicweb040]

@allaneparker There is a serious breakdown in communication somewhere.

It would be "fraudulent" to do a cash pay if they know the patient is in network. The more apt description would be to say the provider would be in violation of their contract, but the "fraud" is probably the way they have described it to front desk staff.

Verify with the provider that they are out of network. That may be the change. Maybe they are now in network but simply not accepting new patients from that insurance. There can be a variety of reasons why a practice would do this. Sometimes the provider is not accepting new patients at all. Sometimes they are not accepting from a certain insurance because their reimbursement rates are too low.

Now, it the provider is out of network they would not have any contractual obligations to accept someone as a new cash patient. But, they don't need any reason to not accept someone as a new patient.

Again, something is not being properly communicated. Not unusual considering how little patients often understand their insurance and that front desk staff often just knows the scripts given to them by management.

 

[av3nger]

@logicweb040 It's not fraud to do self pay if you have insurance. People do it all the time.

 

[waiarlap]

@av3nger Correct, but it may be a violation of the contract between the provider and the insurance company if the provider is aware of it and bills directly to the insured. This would be a problem for the provider and not the patience/insured. Depending on the context it may run afoul of some of the new No Surprises Act requirements without proper releases.

 

[jander8629]

@waiarlap But if they are OON there is no contract.

 

[waiarlap]

@jander8629 Yep, my comment would only be for in-network providers. The out of network provider is not required to file claims to or interact with the insurance company at all barring either of the the scenarios where the patient has no surprises act protections or if there was a state law requiring it.

The potential "fraud" I would see would be if the provider explicitly asked if the client was insured and the patient lied about having insurance to the doctor because they knew the doctor wouldn't see them otherwise or if they thought they could get a better rate via self pay which the provider wouldn't allow if they knew they were insured. It would not be fraud to say "I won't be using my insurance to cover this". I have a hard time imagining many prosecutors would choose to prosecute a case like this though.

 

[signi]

@av3nger It could be fraud if previously they were letting the patient pay an "in network" price for the out-of-network service. At the new office they probably dont' want to do that anymore.

 

[logicweb040]

@av3nger Yes, which is why I described it as being in violation of their contract. Hell, I even put fraudulent in quotes. The point is that the front desk is likely just regurgitating what management has told them.

If the provider is in network and is aware that the patient has in network health insurance, it is a violation of their contract to charge the cash rate.

 

[yochanon]

@av3nger You are correct. With Blue Cross in my state, you just have to sign something at the doctor saying that this visit is not filed on insurance.

 

[pincas]

@allaneparker Our office does not accept self pay because it can be a hassle to collect payment. There are exceptions of course but it’s up to the provider. If your relative is unable to see this doctor anymore, I’d ask for a 90 day refill to give her time to get set up with a new pcp. We do this for people transferring out of the practice if needed.

 

[raptur3ready]

@pincas My GP takes payment BEFORE he will see anyone. He even sends people to an ATM at the 7-Eleven across the street.

 

[acrylic]

@raptur3ready I had a rheumatologist that was in network and pre approved w a referral with the most messed up front office I have ever encountered. I gave up and paid them $150 for a ten minute appointment one time just to get seen. Paid in cash in advance.

Needless to say I don’t see her anymore. She also consistently billed my insurance years after the fact only to get denied.

 

[raptur3ready]

@acrylic Had a dentist like that. $500 for a "free" cleaning

 

[no1texan]

@allaneparker Does she have Medicaid???

 

[allaneparker]

@no1texan No, it’s through her work

 

[foreverthankful]

@allaneparker I mean businesses can refuse service, but it seems odd for them not to accept self-pay. It's not fraud to accept a patient if you don't take their insurance though- that piece they have wrong.

Now, it may be against their agreement with certain insurances to accept self-pay from a member who does have insurance that they take, but since they don't take your insurance, you SHOULD be able to self-pay.

 

[austinrnewton]

@allaneparker Yes, a doctor can refuse to see a patient if they are not in network. This is an important distinction because if they are contracted with the insurance company then they couldn't refuse them. It would be fraud if you had in network insurance and opted to pay cash instead bypassing the contract.

Doctors are business people with contracts, that happen to practice medicine. With the shortage of doctors, some will limit access by what insurance companies that they contract with. There are even doctors that are going with the patient direct model and they have a harder time in limiting their services as they do not have large contracts that they have to fulfil.

 

[manzanopeek]

@austinrnewton Doctors can refuse in-network patients as well. they can't refuse to bill as in-network if they agree to see the patient, but they can choose not to accept new patients. go look at provider network directories and will say "not accepting new patients".

 

[austinrnewton]

@manzanopeek Depends upon the contract with the insurance company. I have sent more than one person to complain to the insurance company about a doctor not accepting a policy holder and miracle of miracles they found an appointment spot for them.

 

[caroylt]

@austinrnewton It’s easier to see the patient than to argue about our autonomy and ability to make decisions. Congratulations, corporate medicine has broken us.