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.

 

[kgr13]

@manzanopeek It seems counter intuitive but I suspect many doctors don't want to deal with self paying patients because collecting payment would be a nightmare.

 

[eaglehaze]

@kgr13 Actually the opposite - they prepay. Healthcare systems do not like it (and they have bought out a lot of practices) because they have a whole system to maximize billing.

 

[waiarlap]

@eaglehaze Prepay is easy for very predictable services, but oftentimes an office visit turns into a minor procedure or a minor procedure turns into a major procedure, etc. etc. and unless the provider pauses treatment and demands additional payment before they continue, then you end up in a situation where collections may be needed.

That being said, I know that some providers do choose the direct pay/concierge route either via a subscription or a per service fee. I expect those providers are providing services that are more limited and less open ended. I don't know of any direct pay/concierge service options that would include more major services though I do know obviously some hospitals/surgeons are willing to accept self-pay patients for more major non-emergency services.

 

[raptur3ready]

@waiarlap Cash is king. Enter their office with a letter of credit for unlimited $$$ and they will be thrilled. What do you think the wealthy do? They have their own private doctors on their payroll.

 

[waiarlap]

@raptur3ready Oh sure, if you put enough down on the table you're good. I expect that the number of people who both have that kind of liquid cash and who do not have health insurance available from a job and choose not to purchase any on their own is quite slim.

For our very wealthy clients, they may not use their health insurance for their concierge doctors, but they still carry it because what we would consider a high premium means a lot less to them and they have a lot more to lose in the event of a major medical event.

 

[aimees]

@kgr13 It seems counter-intuitive because it is counter-factual. Self pre-pay patients are a best case scenario in most situations. Insurance and administrative middlemen siphon a lot of money out of the system.