Why Doctor (PCP) won't allow self-pay?

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FreddieFIRE
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Why Doctor (PCP) won't allow self-pay?

Post by FreddieFIRE »

I am currently insured through Obamacare. I had to change insurance companies during December open enrollment to ensure availability of a certain type of specialty doctor (Retinal Ophthalmologist). As a result of the change, my PCP was no longer in network. I had an appointment scheduled yesterday and decided to keep it and self pay. I was a bit surprised to be met with resistance. Apparently, their group policy is "no self pay allowed." The Doctor tried to explain it to me as an issue with her making referrals but not being in the same network as the doctors/facilities being referred to. My ACA plan does not require a referral for any specialist. Has anybody else encountered this? Can anybody better explain why self pay would be an issue? Thanks.
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Mike Scott
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Re: Why Doctor (PCP) won't allow self-pay?

Post by Mike Scott »

Your doctor's answer is the best one you are going to get. You don't have to like it.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by lereh »

liability maybe. They see you. Refer to a specialist. You don’t go because you can’t afford it. Your condition isn’t fixed. PCP later gets sued? Just a hypothetical.

Billing maybe. Don’t want to worry about bill adjustments after visit that don’t get paid.

Contractual obligations maybe. They are bound by contract to only see patients in networks A, B, and C.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by BuddyJet »

Some Dr practices have rules against referrals outside their network. May be tied to renting office space from that network so they keep referrals close.

I’ve also run across practices that won’t let you move from one provider to another in their practice. This was a problem for my wife since the group has the vast majority of that specialty but my wife didn’t like the Dr she was referred to.
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neurosphere
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Re: Why Doctor (PCP) won't allow self-pay?

Post by neurosphere »

In NY, the referring doctor is liable for the cost if they refer you out of network by mistake. And it's also against the rules for them to accept cash payments if the doctor is in-network.

So what happens if you go to the doctor and actually DO have insurance with them or are in-network?

This has happened to me TWICE, where I provided my insurance card (or asked on the phone) and was told they were not in-network. So I said fine I'll pay cash. And then it turns out they WERE in-network after all and had to refund my credit card payment.

So I can imagine a situation where an office just doesn't want to be involved with that.

And actually, just yesterday I had my first ever doctor's visit in my life (since I was a child anyway) that was at a physician owned practice. And while they were indeed in-network they mentioned that they don't take out of network patients, which I now realize is the same as saying "no self-pay allowed".

Neurosphere

P.S. [Warning a mild rant ahead] And here is my frustration which comes up with a related issue. I've had several doctors or specialists I was referred to who take my insurance, but only in one location. But that location is only for hospital follow-ups. So I can't go there. But because the doctors are IN NETWORK but at a location I AM NOT ALLOWED TO GO TO, I then CANNOT just pay cash. That's not something they tell you when you see a nice big list of in-network physicians on the insurance website.

Sorry for yelling lol. :D The irony is that all my doctors were providers at the same institution where I was also a physician for 15 years. So for all I know "I" did the same to others.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by Dusn »

Sounds like this doctor is employed? If they’re employed, they’re not making the rules anyway. And honestly, if some hospital administrators or PE were taking most of the pay for the work I did, I wouldn’t bother understanding how the billing works either.

I’d ask the billing office if you haven’t done so already.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by FreddieFIRE »

Thanks for the replies. Fortunately, I'll be on Medicare later this year and free from most/all of this kind of stuff. I may establish a relationship with a new PCP that my new insurance covers ($5 PCP co-pay, so basically free and a two mile drive). Not sure if that will be worth the bother or not.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by FreddieFIRE »

Dusn wrote: Thu Jan 16, 2025 6:01 pm Sounds like this doctor is employed? If they’re employed, they’re not making the rules anyway. And honestly, if some hospital administrators or PE were taking most of the pay for the work I did, I wouldn’t bother understanding how the billing works either.

I’d ask the billing office if you haven’t done so already.
It's pretty much water under the bridge at this point. I had my physical. I paid. I got my test orders and results. Same as every year. Not perfect. Not dead yet. I was mostly hoping to better understand why this seemed to be a pretty big issue for their office.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by FreddieFIRE »

neurosphere wrote: Thu Jan 16, 2025 5:43 pm In NY, the referring doctor is liable for the cost if they refer you out of network by mistake.
That's the odd thing. My insurance does not require referrals for any specialists. I can set up an appointment with anybody I want without my PCP's involvement.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by Dusn »

BuddyJet wrote: Thu Jan 16, 2025 5:12 pm Some Dr practices have rules against referrals outside their network. May be tied to renting office space from that network so they keep referrals close.

I’ve also run across practices that won’t let you move from one provider to another in their practice. This was a problem for my wife since the group has the vast majority of that specialty but my wife didn’t like the Dr she was referred to.
This is done to prevent burnout of the nicest doctors in the practice. As you’d imagine, often it’s the more demanding patients who switch. Then all the most demanding patients end up with the most patient, compassionate doctor. That doctor then has trouble keeping up with her schedule because her patients take more time. She then learns that she either needs to become less nice or insist that patients be randomly assigned and stay with their original provider.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by neurosphere »

FreddieFIRE wrote: Thu Jan 16, 2025 6:07 pm
neurosphere wrote: Thu Jan 16, 2025 5:43 pm In NY, the referring doctor is liable for the cost if they refer you out of network by mistake.
That's the odd thing. My insurance does not require referrals for any specialists. I can set up an appointment with anybody I want without my PCP's involvement.
It don't think it's necessary to have a referral requirement, although admittedly it's not clear how the phrase in italics refers to the previous sentences.
You are also protected from surprise bills when an in-network doctor refers you to an out-of-network provider. This includes services you get when you are in your doctor’s office, when your doctor sends a sample taken from you to an out-of-network lab or pathologist, and for other health care services when a referral is required and you received a referral from your in-network doctor.
https://www.dfs.ny.gov/consumers/health ... prises_act

Anyway, the new No Surprises act has been great for me. I choose a cheaper plan with a more limited network. I just (try to! LOL) self-pay for any outpatient care. The decreased premiums more than make up for the out of network costs. But inpatient care and emergency care will always be in network because all the hospitals in my area are in-network for inpatient coverage. And if by chance that notorious OON anesthesiologists subs in for the under-the-weather in-network dude(tte), they can't bill me the OON rates like they used to do.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by neurosphere »

Dusn wrote: Thu Jan 16, 2025 6:13 pm
BuddyJet wrote: Thu Jan 16, 2025 5:12 pm Some Dr practices have rules against referrals outside their network. May be tied to renting office space from that network so they keep referrals close.

I’ve also run across practices that won’t let you move from one provider to another in their practice. This was a problem for my wife since the group has the vast majority of that specialty but my wife didn’t like the Dr she was referred to.
This is done to prevent burnout of the nicest doctors in the practice. As you’d imagine, often it’s the more demanding patients who switch. Then all the most demanding patients end up with the most patient, compassionate doctor. That doctor then has trouble keeping up with her schedule because her patients take more time. She then learns that she either needs to become less nice or insist that patients be randomly assigned and stay with their original provider.
That's part of it yes. But in my experience the bigger reason our specialty did not allow it (except when both docs agreed) was to prevent situations where one doc had to change the treatment plan of another. I was a neurologist with a specialty in epilepsy. And for most epilepsies there may be up to 10 perfectly reasonable medications to try, doses to try, etc. ALL of us had our "favorites". On DOZENS of occasions I had patients of mine seen by other doctors (while traveling, when I was on vacation, when patients were hospitalized and under another's care for inpatient stuff) who made minor tweaks to a treatment and many times those docs were colleagues and friends. But then the patient would ask "But Dr. Neurosphere said I should do X and you are saying to do Y and thus one of you is a quack" (paraphrase). And I would then have to explain that both X and Y are basically the same, and that even I might have said to do X one day by then Y the next based on my mood that day.

As an aside, I used to volunteer within our group to take on a particularly difficult kind of diagnosis, one that most docs very much hate to treat (time consuming, hard to explain, patients don't like the diagnosis, etc). At the end of the year admin would compare my productivity with the others and wonder why I was lagging. I told admin that all they had to do was mention to the other docs that this diagnosis type would now be shared equally with the group rather than being referred directly to me as the sub-sub-specialist for that condition. There was an outcry among the docs, and it left me some breathing room until the next year when the productivity issue came up again, and perhaps not-so-coincidentally, that's when I retired from medicine. :mrgreen:
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Re: Why Doctor (PCP) won't allow self-pay?

Post by neurosphere »

FreddieFIRE wrote: Thu Jan 16, 2025 6:06 pm It's pretty much water under the bridge at this point. I had my physical. I paid. I got my test orders and results. Same as every year. Not perfect. Not dead yet. I was mostly hoping to better understand why this seemed to be a pretty big issue for their office.
But this thread is now included among the wealth of info on this site and will likely help dozens (hundreds? thousands?) of folks who had a similar question.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by FreddieFIRE »

neurosphere wrote: Thu Jan 16, 2025 6:36 pm
FreddieFIRE wrote: Thu Jan 16, 2025 6:06 pm It's pretty much water under the bridge at this point. I had my physical. I paid. I got my test orders and results. Same as every year. Not perfect. Not dead yet. I was mostly hoping to better understand why this seemed to be a pretty big issue for their office.
But this thread is now included among the wealth of info on this site and will likely help dozens (hundreds? thousands?) of folks who had a similar question.
Yep. Thanks. If this has been brought up here before, I missed it.

The background question here is "is a retina detachment an emergency?"

Let's assume "yes," which would likely be the answer received from any ophthalmologist or other eyecare professional. What if I had a detached retina and only one in-network retinal ophthalmologist in my state and he was on vacation? Would the out-of-network retinal ophthalmologists have the same answer as my PCP's office (i.e. we can't take cash pay, out of network patients). This is my true underlying issue, although I'm trying not to cross the line into discussion of medical conditions here on the forum. Even before my being educated that cash is no longer king, this drove my switch in insurance. Four risk factors and a recent scare were all it took. :annoyed
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Re: Why Doctor (PCP) won't allow self-pay?

Post by Supergrover »

neurosphere wrote: Thu Jan 16, 2025 5:43 pm
P.S. [Warning a mild rant ahead] And here is my frustration which comes up with a related issue. I've had several doctors or specialists I was referred to who take my insurance, but only in one location. But that location is only for hospital follow-ups. So I can't go there. But because the doctors are IN NETWORK but at a location I AM NOT ALLOWED TO GO TO, I then CANNOT just pay cash. That's not something they tell you when you see a nice big list of in-network physicians on the insurance website.

Sorry for yelling lol. :D The irony is that all my doctors were providers at the same institution where I was also a physician for 15 years. So for all I know "I" did the same to others.
The fact that you’re a physician and it’s the same institution you worked at is unbelievable. The system is broken in many places.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by BassHead »

Supergrover wrote: Thu Jan 16, 2025 7:19 pm
neurosphere wrote: Thu Jan 16, 2025 5:43 pm
P.S. [Warning a mild rant ahead] And here is my frustration which comes up with a related issue. I've had several doctors or specialists I was referred to who take my insurance, but only in one location. But that location is only for hospital follow-ups. So I can't go there. But because the doctors are IN NETWORK but at a location I AM NOT ALLOWED TO GO TO, I then CANNOT just pay cash. That's not something they tell you when you see a nice big list of in-network physicians on the insurance website.

Sorry for yelling lol. :D The irony is that all my doctors were providers at the same institution where I was also a physician for 15 years. So for all I know "I" did the same to others.
The fact that you’re a physician and it’s the same institution you worked at is unbelievable. The system is broken in many places.
People still think the doctor is in charge for some reason. The doctor is an employee just like the lady at the front desk who check you in. It's like the airline pilot flies the plane but doesn't own it and doesn't know what food they are serving in the back.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by FreddieFIRE »

BassHead wrote: Thu Jan 16, 2025 11:33 pm
Supergrover wrote: Thu Jan 16, 2025 7:19 pm

The fact that you’re a physician and it’s the same institution you worked at is unbelievable. The system is broken in many places.
People still think the doctor is in charge for some reason. The doctor is an employee just like the lady at the front desk who check you in. It's like the airline pilot flies the plane but doesn't own it and doesn't know what food they are serving in the back.
Yeah. I get that, and I knew that going into this. Megacorp (of all sizes) can be stupid. I paid $240 cash for what would have brought a contracted rate of $160 from the previous in-network insurer. Why? Well, some have attempted to explain, but I'm not entirely convinced that there isn't some level of stupid mixed in here. One month ago an in-network ophthalmologist generated a referral to an out-of-network retinal ophthalmologist. I was the one who checked and identified the out-of-network problem. Why wasn't that doctor concerned with this network noise? I corrected it through a fortunate open enrollment window. Yes, I know, I'm shouting into an echo chamber here. :oops: Anyways, I'll be fine. Medicare is only months away and then I can look forward to a new set of challenges. That said, I'm going basic Medicare plus G-HD (see my other thread) and darned near everybody takes that. 8-)
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Re: Why Doctor (PCP) won't allow self-pay?

Post by planetmike »

Part of me says that doctors don't accept self-pay/cash because they don't know how much something costs. With InsuranceA the procedure gains the office $200 ($175 from insurance and $25 copay from patient). With InsuranceB the procedure gains the office $225 ($180 from insurance and $45 copay from patient). With Medicare plus InsuranceC the office gains $140 ($75 from Medicare, $55 from insurance, $10 copay from patient).

The US healthcare system is incredibly busted.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by FreddieFIRE »

planetmike wrote: Fri Jan 17, 2025 7:03 am Part of me says that doctors don't accept self-pay/cash because they don't know how much something costs. With InsuranceA the procedure gains the office $200 ($175 from insurance and $25 copay from patient). With InsuranceB the procedure gains the office $225 ($180 from insurance and $45 copay from patient). With Medicare plus InsuranceC the office gains $140 ($75 from Medicare, $55 from insurance, $10 copay from patient).

The US healthcare system is incredibly busted.
This was a routine annual physical. I paid $241. That is what they would have billed insurance, but they would have received a lesser contracted rate and it would take a few weeks.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by clip651 »

FreddieFIRE wrote: Fri Jan 17, 2025 12:00 pm
planetmike wrote: Fri Jan 17, 2025 7:03 am Part of me says that doctors don't accept self-pay/cash because they don't know how much something costs. With InsuranceA the procedure gains the office $200 ($175 from insurance and $25 copay from patient). With InsuranceB the procedure gains the office $225 ($180 from insurance and $45 copay from patient). With Medicare plus InsuranceC the office gains $140 ($75 from Medicare, $55 from insurance, $10 copay from patient).

The US healthcare system is incredibly busted.
This was a routine annual physical. I paid $241. That is what they would have billed insurance, but they would have received a lesser contracted rate and it would take a few weeks.
And in the current system, that is basically the financial punishment of you going out of network. You're lucky they saw you at all as an out of network patient.

I had a primary doctor refuse to even book an appointment slot until my new insurance (where they were in network again) was in effect. (e.g. I called in December, knowing that they would be in network on my next ACA policy January 1st, and they would not even allow me to schedule an appointment prior to January 1. So I had to call back in January, and then wait several weeks or months to get an appointment slot. No option for cash pay whatsoever, not even to say I'd pay cash if there was any issue but please at least give me a slot on the schedule. And I had been a patient there in previous years as an in network patient.)
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Re: Why Doctor (PCP) won't allow self-pay?

Post by FreddieFIRE »

clip651 wrote: Fri Jan 17, 2025 12:42 pm And in the current system, that is basically the financial punishment of you going out of network. You're lucky they saw you at all as an out of network patient.
This had nothing to do with financial punishment. This is a family Doctor that DW, DD, DS and I have had for years. I don't think luck had anything to do with it. She books a year out and (fortuntaely?) we already had our January 2026 appointments scheduled, when I'll be on Medicare and DW will be back in network. And this isn't an office that is in network for ANY HMO plans, so needing a PCP to refer to specialists is largely irrelevant (at least based upon my limited understanding). All that said, it's water under the bridge and hopefully a lesson learned (for others, who have to wrestle with this stuff for years before Medicare). I already had sworn off Medicare Advantage, for both the known and the unknown.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by James.534 »

Is this plan an ACA plan that is subsidized at least in part by the government. If so we can not bill a patient a self pay, when we accept the plan , but not that specific insurance product.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by FreddieFIRE »

James.534 wrote: Fri Jan 17, 2025 1:40 pm Is this plan an ACA plan that is subsidized at least in part by the government. If so we can not bill a patient a self pay, when we accept the plan , but not that specific insurance product.
If I'm not using any insurance, why would any of that matter? What is the difference between "an ACA plan" and a "specific insurance product?"
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Re: Why Doctor (PCP) won't allow self-pay?

Post by James.534 »

If a patient has a medical assistance plan, in my state it is not legal to bill the patient cash rate and "not use" the plan.

Sometimes patients come in and want to pay cash , but have high deductibles , so it may to be to their advantage to pay cash from a pricing stand point. For example, we have a contract with BC/BS , so by contractual agreement between us and BC/BS we need to charge them and submit to BCBS we/the patient can not pick and choose whether or not they want to use the insurance if they are insured.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by FreddieFIRE »

James.534 wrote: Fri Jan 17, 2025 2:00 pm If a patient has a medical assistance plan, in my state it is not legal to bill the patient cash rate and "not use" the plan.

Sometimes patients come in and want to pay cash , but have high deductibles , so it may to be to their advantage to pay cash from a pricing stand point. For example, we have a contract with BC/BS , so by contractual agreement between us and BC/BS we need to charge them and submit to BCBS we/the patient can not pick and choose whether or not they want to use the insurance if they are insured.
I appreciate the input, but none of this was mentioned. Only the issue of referrals, which my insurance does not require.

That said, are you suggesting that I might have run into the same problem trying to get immediate emergency surgery from an out-of-network ophthalmologist? That's scary.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by AnEngineer »

FreddieFIRE wrote: Fri Jan 17, 2025 2:34 pm I appreciate the input, but none of this was mentioned. Only the issue of referrals, which my insurance does not require.
But the doctor may be required to make a referral under some conditions. Referral does not always mean that the doc is allowing you to go somewhere. Many plans have no referral requirement, but doctors still do it. (Also, some practices require it even if your insurance doesn't.) Also, sometimes when there's a rule you aren't given the real reason, either because they don't understand, there's a game of telephone going on, or they're lying.
FreddieFIRE wrote: Fri Jan 17, 2025 2:34 pm That said, are you suggesting that I might have run into the same problem trying to get immediate emergency surgery from an out-of-network ophthalmologist? That's scary.
No Surprises Act requires all emergency care to be treated as in network. (Even before that I think theres an expectation of treating the emergency and worrying about billing later.) A reasonable person's definition of 'emergency' may not completely align with the legal definition.
That your facts or argument are wrong does not necessarily mean I disagree with your conclusion
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Re: Why Doctor (PCP) won't allow self-pay?

Post by LoveTheBogle »

Just follow the money.

The doctor doesn’t want self pay there is liability with the referral that exists with self pay patients or self pay patients don’t pay or try to negotiate the fees.

It is self serving 100%. Find a different PCP who isn’t practicing 100% for monetary reasons (good luck).

Edit: I removed an option of it being the doctor getting a kickback for the referral but can’t if it is insurance which is inaccurate.
Last edited by LoveTheBogle on Sat Jan 18, 2025 8:37 pm, edited 1 time in total.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by techbud »

James.534 wrote: Fri Jan 17, 2025 2:00 pm If a patient has a medical assistance plan, in my state it is not legal to bill the patient cash rate and "not use" the plan.
I believe (but might be incorrect) that what you are referring to as "a medical assistance plan" is Medicaid, and for that your assertion is correct. But for ACA plans, even if you are receiving subsidies and/or PTC (premium tax credit), I don't think that is a "medical assistance plan" that restricts you from doing self-pay with any provider.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by Dontsell1 »

LoveTheBogle wrote: Sat Jan 18, 2025 10:30 am Just follow the money.

The doctor doesn’t want self pay because of no ability to get a kickback from a referral, there is liability with the referral that exists with self pay patients or self pay patients don’t pay or try to negotiate the fees.

It is self serving 100%. Find a different PCP who isn’t practicing 100% for monetary reasons (good luck).
lol. I’d love to find me some of these kickbacks you speak of with such confidence.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by techbud »

LoveTheBogle wrote: Sat Jan 18, 2025 10:30 am Just follow the money.

The doctor doesn’t want self pay because of no ability to get a kickback from a referral
Wow, you just used a broad stroke to paint an entire profession as unethical. What you insinuate is illegal under Federal and State laws:

https://fhicommunications.com/permissib ... k-statute/
https://ddpalaw.com/blog/healthcare-law ... k-statute/
https://www.superlawyers.com/resources/ ... alth-care/
https://www.kalantar.law/what-is-consid ... ealthcare/

Care to retract that statement?
(FWIW, I am not a doctor nor have I ever worked in the healthcare industry)
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Re: Why Doctor (PCP) won't allow self-pay?

Post by curious george »

It is so complex
My father-in-law had a complex case and we wanted to go to MD Anderson for a consultation
Insurance was complex and full of red tape
Consult cost was a few hundred so I wanted to just pay cash

They refused cash if you are insured. I say again- they REFUSED CASH.
They have complex rules from insurance companies and we had to go the long route through getting prior authorization form insurance costing much more in time and effort than the cash cost of the consult. They will only accept cash if you are truly uninsured.

They have contracts that prevent them from taking cash pay for any insurance in which they participate even if it is a different plan in which they do not participate.

In one local practice, some docs are in-network but others are not. Insurance company would not let others doctors apply for in-network and they have been trying for years. So insurance company is making

Healthcare is so complex that I would bet there isn’t a single person in America who can explain the details of every aspect of the current system from hospitals, doctors, insurances, labs/testing
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Re: Why Doctor (PCP) won't allow self-pay?

Post by WeakOldGuy »

LoveTheBogle wrote: Sat Jan 18, 2025 10:30 am Just follow the money.

The doctor doesn’t want self pay because of no ability to get a kickback from a referral, there is liability with the referral that exists with self pay patients or self pay patients don’t pay or try to negotiate the fees.
A "kickback" is not a thing. There is always the risk of non-payment of a bill for a private pay patient. However, there are also risks of non-payment from an insurance company.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by WeakOldGuy »

FreddieFIRE wrote: Fri Jan 17, 2025 2:34 pm
James.534 wrote: Fri Jan 17, 2025 2:00 pm If a patient has a medical assistance plan, in my state it is not legal to bill the patient cash rate and "not use" the plan.

Sometimes patients come in and want to pay cash , but have high deductibles , so it may to be to their advantage to pay cash from a pricing stand point. For example, we have a contract with BC/BS , so by contractual agreement between us and BC/BS we need to charge them and submit to BCBS we/the patient can not pick and choose whether or not they want to use the insurance if they are insured.
I appreciate the input, but none of this was mentioned. Only the issue of referrals, which my insurance does not require.

That said, are you suggesting that I might have run into the same problem trying to get immediate emergency surgery from an out-of-network ophthalmologist? That's scary.
There may be differences by state as well as region and community. I was fortunate in over 40 years of practice I never had a patient I referred for a retinal detachment not be seen by the retinal specialist I called.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by Doctor Rhythm »

LoveTheBogle wrote: Sat Jan 18, 2025 10:30 am Just follow the money.

The doctor doesn’t want self pay because of no ability to get a kickback from a referral...
Are you saying OP's primary care provider is likely getting kickbacks in violation of criminal law? This would be a really serious accusation, and if proven, could mean jail time.

Besides, I don't even see how cash payment to PCP would prevent this.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by LoveTheBogle »

techbud wrote: Sat Jan 18, 2025 11:23 am
LoveTheBogle wrote: Sat Jan 18, 2025 10:30 am Just follow the money.

The doctor doesn’t want self pay because of no ability to get a kickback from a referral
Wow, you just used a broad stroke to paint an entire profession as unethical. What you insinuate is illegal under Federal and State laws:

https://fhicommunications.com/permissib ... k-statute/
https://ddpalaw.com/blog/healthcare-law ... k-statute/
https://www.superlawyers.com/resources/ ... alth-care/
https://www.kalantar.law/what-is-consid ... ealthcare/

Care to retract that statement?
(FWIW, I am not a doctor nor have I ever worked in the healthcare industry)
Retracted and I edited my post. I didn’t know it was illegal. With my very limited (thankfully) interaction with the healthcare industry it feels like absolutely everything is about the Benjamin’s. I was also recently at the doctor who mentioned multiple times about writing up a referral even though I told him multiple times that my insurance doesn’t require it and the specialist office doesn’t either. Even still, he wrote it up and gave me it and then when I went to the office the specialist mentioned “I got a referral from doctor xyz”. I figured there was absolutely no good reason whatsoever for my doctor to be so persistent about doing a referral when I told him not needed, no thanks, I may choose someone else, etc multiple times and then he did it anyway. Scratching my head as to why he did that. It wasn’t even a big deal (nothing serious at all and couldn’t ever be construed as serious….. small annoyance but nothing serious so I ruled out to get rid of potential liability if he didn’t refer. He could have easily just documented it in my chart that he recommended I go see specialist.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by FreddieFIRE »

WeakOldGuy wrote: Sat Jan 18, 2025 6:36 pm
FreddieFIRE wrote: Fri Jan 17, 2025 2:34 pm

I appreciate the input, but none of this was mentioned. Only the issue of referrals, which my insurance does not require.

That said, are you suggesting that I might have run into the same problem trying to get immediate emergency surgery from an out-of-network ophthalmologist? That's scary.
There may be differences by state as well as region and community. I was fortunate in over 40 years of practice I never had a patient I referred for a retinal detachment not be seen by the retinal specialist I called.
Thanks for the info. I just didn’t want to take the risk. While a detached retina is certainly an emergency to the patient, it in no way is life threatening which might creep into the medical equation. Who wants to “wait and see?” Not me, thank you.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by FreddieFIRE »

AnEngineer wrote: Sat Jan 18, 2025 7:22 am
FreddieFIRE wrote: Fri Jan 17, 2025 2:34 pm I appreciate the input, but none of this was mentioned. Only the issue of referrals, which my insurance does not require.
But the doctor may be required to make a referral under some conditions. Referral does not always mean that the doc is allowing you to go somewhere. Many plans have no referral requirement, but doctors still do it. (Also, some practices require it even if your insurance doesn't.) Also, sometimes when there's a rule you aren't given the real reason, either because they don't understand, there's a game of telephone going on, or they're lying.
FreddieFIRE wrote: Fri Jan 17, 2025 2:34 pm That said, are you suggesting that I might have run into the same problem trying to get immediate emergency surgery from an out-of-network ophthalmologist? That's scary.
No Surprises Act requires all emergency care to be treated as in network. (Even before that I think theres an expectation of treating the emergency and worrying about billing later.) A reasonable person's definition of 'emergency' may not completely align with the legal definition.
Does the no surprises act clearly define a detached retina as an included emergency?
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Re: Why Doctor (PCP) won't allow self-pay?

Post by AnEngineer »

FreddieFIRE wrote: Sun Jan 19, 2025 7:11 am
AnEngineer wrote: Sat Jan 18, 2025 7:22 am
But the doctor may be required to make a referral under some conditions. Referral does not always mean that the doc is allowing you to go somewhere. Many plans have no referral requirement, but doctors still do it. (Also, some practices require it even if your insurance doesn't.) Also, sometimes when there's a rule you aren't given the real reason, either because they don't understand, there's a game of telephone going on, or they're lying.


No Surprises Act requires all emergency care to be treated as in network. (Even before that I think theres an expectation of treating the emergency and worrying about billing later.) A reasonable person's definition of 'emergency' may not completely align with the legal definition.
Does the no surprises act clearly define a detached retina as an included emergency?
You'd have to go look. I doubt the law itself does (if by clearly you mean explicitly), but there may be precedent or some agency list.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by michaeljc70 »

FreddieFIRE wrote: Fri Jan 17, 2025 12:00 pm
planetmike wrote: Fri Jan 17, 2025 7:03 am Part of me says that doctors don't accept self-pay/cash because they don't know how much something costs. With InsuranceA the procedure gains the office $200 ($175 from insurance and $25 copay from patient). With InsuranceB the procedure gains the office $225 ($180 from insurance and $45 copay from patient). With Medicare plus InsuranceC the office gains $140 ($75 from Medicare, $55 from insurance, $10 copay from patient).

The US healthcare system is incredibly busted.
This was a routine annual physical. I paid $241. That is what they would have billed insurance, but they would have received a lesser contracted rate and it would take a few weeks.
Including lab work? Because my annual physical cost consists mostly of lab work and the "list" price is around $1300.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by AnEngineer »

planetmike wrote: Fri Jan 17, 2025 7:03 am Part of me says that doctors don't accept self-pay/cash because they don't know how much something costs. With InsuranceA the procedure gains the office $200 ($175 from insurance and $25 copay from patient). With InsuranceB the procedure gains the office $225 ($180 from insurance and $45 copay from patient). With Medicare plus InsuranceC the office gains $140 ($75 from Medicare, $55 from insurance, $10 copay from patient).

The US healthcare system is incredibly busted.
In my experience, everything I get a a medical bill for has a higher initial price before the insurance negotiated rate.
That your facts or argument are wrong does not necessarily mean I disagree with your conclusion
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Re: Why Doctor (PCP) won't allow self-pay?

Post by FreddieFIRE »

michaeljc70 wrote: Sun Jan 19, 2025 8:15 am
FreddieFIRE wrote: Fri Jan 17, 2025 12:00 pm

This was a routine annual physical. I paid $241. That is what they would have billed insurance, but they would have received a lesser contracted rate and it would take a few weeks.
Including lab work? Because my annual physical cost consists mostly of lab work and the "list" price is around $1300.
No. I get the lab work at an in network lab.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by WeakOldGuy »

FreddieFIRE wrote: Sun Jan 19, 2025 7:06 am
Thanks for the info. I just didn’t want to take the risk. While a detached retina is certainly an emergency to the patient, it in no way is life threatening which might creep into the medical equation. Who wants to “wait and see?” Not me, thank you.
Wise decision. There is a window of about 5-7 days where a reattachment procedure is highly successful. Beyond that, the success rate goes down significantly. I would consider it an emergency, but then at times insurance companies didn't necessarily agree with my opinion.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by White Coat Investor »

FreddieFIRE wrote: Thu Jan 16, 2025 4:54 pm I am currently insured through Obamacare. I had to change insurance companies during December open enrollment to ensure availability of a certain type of specialty doctor (Retinal Ophthalmologist). As a result of the change, my PCP was no longer in network. I had an appointment scheduled yesterday and decided to keep it and self pay. I was a bit surprised to be met with resistance. Apparently, their group policy is "no self pay allowed." The Doctor tried to explain it to me as an issue with her making referrals but not being in the same network as the doctors/facilities being referred to. My ACA plan does not require a referral for any specialist. Has anybody else encountered this? Can anybody better explain why self pay would be an issue? Thanks.
It's because "self-pay" usually means "no-pay." Our collections rate on our self pay patients was like 3% last I looked.

If they could figure out what your bill should be and make you pay it in advance that would be one thing. Pretty much impossible in the ER and not all that easy in clinic either.

Not sure which of those two reasons is the main one why they don't want your money, but I bet it's one of those things. The referral thing seems bizarre. But I'm not surprised to hear of a doc who doesn't really understand what's going on behind the scenes with the money/system. Docs don't get any training in this sort of stuff.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by White Coat Investor »

curious george wrote: Sat Jan 18, 2025 12:28 pm
They have contracts that prevent them from taking cash pay for any insurance in which they participate even if it is a different plan in which they do not participate.


Healthcare is so complex that I would bet there isn’t a single person in America who can explain the details of every aspect of the current system from hospitals, doctors, insurances, labs/testing
That's another possibility too, that their insurance contracts don't allow them to take self-pay patients. But that's not about referrals.

Totally agree with your last statement.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by White Coat Investor »

lereh wrote: Thu Jan 16, 2025 5:08 pm liability maybe. They see you. Refer to a specialist. You don’t go because you can’t afford it. Your condition isn’t fixed. PCP later gets sued? Just a hypothetical.
Why would the doc be liable because the patient doesn't follow instructions or is poor? I mean, you can sue for anything, but I don't think that case is going to be taken by a competent attorney very often. In fact, I'm pretty sure the lower the intelligence and the fewer assets the patient has, the LESS likely they are to bring suit successfully. It takes a fair amount of ability and assets to see a 4 or 5 year lawsuit through to the end. It might not be fair, but welcome to America. If that attorney isn't sure the patient is going to make it back to their office, they're not going to spend $100K hoping to win on contingency even when they think the case is decent.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by FreddieFIRE »

White Coat Investor wrote: Sun Jan 19, 2025 7:48 pm It's because "self-pay" usually means "no-pay." Our collections rate on our self pay patients was like 3% last I looked.
I paid at the appointment. Thanks for your valuable inputs.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by Northern Flicker »

FreddieFIRE wrote: Mon Feb 03, 2025 12:44 am
White Coat Investor wrote: Sun Jan 19, 2025 7:48 pm It's because "self-pay" usually means "no-pay." Our collections rate on our self pay patients was like 3% last I looked.
I paid at the appointment. Thanks for your valuable inputs.
White Coat Investor clearly was providing a plausible motivation for the policy, and not an assessment of your particular situation.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by techbud »

White Coat Investor wrote: Sun Jan 19, 2025 7:48 pm
FreddieFIRE wrote: Thu Jan 16, 2025 4:54 pm I am currently insured through Obamacare. I had to change insurance companies during December open enrollment to ensure availability of a certain type of specialty doctor (Retinal Ophthalmologist). As a result of the change, my PCP was no longer in network. I had an appointment scheduled yesterday and decided to keep it and self pay. I was a bit surprised to be met with resistance. Apparently, their group policy is "no self pay allowed." The Doctor tried to explain it to me as an issue with her making referrals but not being in the same network as the doctors/facilities being referred to. My ACA plan does not require a referral for any specialist. Has anybody else encountered this? Can anybody better explain why self pay would be an issue? Thanks.
It's because "self-pay" usually means "no-pay." Our collections rate on our self pay patients was like 3% last I looked.

If they could figure out what your bill should be and make you pay it in advance that would be one thing. Pretty much impossible in the ER and not all that easy in clinic either.
Respectfully, as I know you are a physician and I am simply a consumer, I have had numerous self-pay encounters with different providers (urgent care, dermatologist, imaging, optometrist, etc) and in all cases, they quoted the self-pay rate to me and asked me to pay at the time of the visit. I got a fair rate as they didn't have to deal with any paperwork and they got their payment up front. I acknowledge your point that this works for well defined encounters such as imaging or a skin check, but would not work well for open-ended encounters such as an ER visit. It's definitely possible for urgent care; example: Here's a link to a local to me (Miami) urgent care system which shows the self-pay prices and clearly states "Pay in full today and a discount will be applied": https://baptisthealth.net/locations/urg ... ash-prices

Similarly, I am aware that some service providers (eg, hospitals) are required to quote their prices for standard procedures online, and these include the "self-pay" rate. I have used this system to comparison shop for non-critical medical services. Here are two local to me (Miami) hospital systems and their associated websites: https://jacksonhealth.org/patient-tools ... ansparency and https://umiamihealth.org/billing-,-a-,- ... n-estimate With either of these, you can enter a CPT code and find out the cost for insured vs self-pay.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by White Coat Investor »

techbud wrote: Mon Feb 03, 2025 10:14 am
White Coat Investor wrote: Sun Jan 19, 2025 7:48 pm

It's because "self-pay" usually means "no-pay." Our collections rate on our self pay patients was like 3% last I looked.

If they could figure out what your bill should be and make you pay it in advance that would be one thing. Pretty much impossible in the ER and not all that easy in clinic either.
Respectfully, as I know you are a physician and I am simply a consumer, I have had numerous self-pay encounters with different providers (urgent care, dermatologist, imaging, optometrist, etc) and in all cases, they quoted the self-pay rate to me and asked me to pay at the time of the visit. I got a fair rate as they didn't have to deal with any paperwork and they got their payment up front. I acknowledge your point that this works for well defined encounters such as imaging or a skin check, but would not work well for open-ended encounters such as an ER visit. It's definitely possible for urgent care; example: Here's a link to a local to me (Miami) urgent care system which shows the self-pay prices and clearly states "Pay in full today and a discount will be applied": https://baptisthealth.net/locations/urg ... ash-prices

Similarly, I am aware that some service providers (eg, hospitals) are required to quote their prices for standard procedures online, and these include the "self-pay" rate. I have used this system to comparison shop for non-critical medical services. Here are two local to me (Miami) hospital systems and their associated websites: https://jacksonhealth.org/patient-tools ... ansparency and https://umiamihealth.org/billing-,-a-,- ... n-estimate With either of these, you can enter a CPT code and find out the cost for insured vs self-pay.
Cool. More of this is a good thing.
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Re: Why Doctor (PCP) won't allow self-pay?

Post by FreddieFIRE »

Mike Scott wrote: Thu Jan 16, 2025 5:00 pm Your doctor's answer is the best one you are going to get. You don't have to like it.
In retrospect, this didn't age very well. I appreciate the many helpful responses.
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