Will California out-of-network physicians accept private pay from a Kaiser member?

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msj16
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Will California out-of-network physicians accept private pay from a Kaiser member?

Post by msj16 »

Naive question about finance/non-medical issue here:

We are relocating to California. One family member may have to be enrolled in a research study only available at a Kaiser facility. That means that the whole family may have to enroll in Kaiser Permanente member plan although we have always had a PPO and liberally saw out of network doctors. We are considering signing up for Kaiser but just paying out of pocket for any out of network office visits received. Luckily we have the resources to cover additional health costs at this time.

Now with the popularity of HSA's, do physicians billing offices readily take a credit card for payment? Do you have to give pre-payment in advance? What is a typical charge for a specialist office visit if it is private pay?


Your guidance is appreciated!
msj16
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Watty
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Re: Will California out-of-network physicians accept private pay from a Kaiser member?

Post by Watty »

A big problem you will have is that all the billing will be at the ridiculous "Chargmaster" computerized rates where something may be charged $1000 but the PPO rate that you are used to seeing was reduced to $50. They are literally that extreme. If you have any recent explanation of benefits then you can look at those to see how much they were reduced.

When you are in a PPO and have a HSA you would still get the lower $50 rate so that is a different situation.

I suspect that many doctors will be reluctant to see you when you do not have insurance even if you are willing to prepay. The reason is that they can be sued for malpractice if they do not provide follow-up care even if you do not pay your bills. This is called "abandonment".

https://www.nolo.com/legal-encyclopedia ... nment.html

Nothing is perfect but Kaiser actually has a really good reputation.
Rex66
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Re: Will California out-of-network physicians accept private pay from a Kaiser member?

Post by Rex66 »

I charge self pay Medicare rates personally

You can find some willing to do that but I’d just go with Kaiser given what u posted
rich126
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Re: Will California out-of-network physicians accept private pay from a Kaiser member?

Post by rich126 »

All medical offices that have required a payment while I was in the office, have accepted credit cards for as long as I can remember. Only some old timers use checks, certainly not me and I'm late 50s.
Big Dog
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Re: Will California out-of-network physicians accept private pay from a Kaiser member?

Post by Big Dog »

Yes, docs are more than happy to take cash/check/credit card on the day of service. But you will be paying sticker, not a discounted PPO rate. Besides the doc, are you prepared to pay rack rate should you need to be hospitalized?

Kaiser can be excellent in CA, so suggest you give them a chance.
quantAndHold
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Re: Will California out-of-network physicians accept private pay from a Kaiser member?

Post by quantAndHold »

If you’re relocating and have to choose new docs anyway, why would you not just use Kaiser docs? Kaiser is quite good.
Yes, I’m really that pedantic.
EnjoyIt
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Re: Will California out-of-network physicians accept private pay from a Kaiser member?

Post by EnjoyIt »

Yes, docs take credit cards.
Discuss cash rates with them in advance. Many will charge a very reasonable cash rate.
It is to the physicians advantage to take cash/credit card on date of service than to have to deal with insurance.
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supalong52
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Re: Will California out-of-network physicians accept private pay from a Kaiser member?

Post by supalong52 »

quantAndHold wrote: Wed Jun 09, 2021 10:05 am If you’re relocating and have to choose new docs anyway, why would you not just use Kaiser docs? Kaiser is quite good.
I would say Kaiser is very good for primary care, but if you need a specialist then you might want to look elsewhere. A family member required brain surgery and the Kaiser doctor suggested taking out the entire lobe tip. We got a second opinion and the head of vascular neurosurgery at UCSF shook his head and said their techniques were downright primitive. They switched out of Kaiser during open enrollment so they could get the surgery elsewhere.

On the other end of the spectrum, I was also on Kaiser for a year or two and had to stay in the hospital. My total out of pocket expense for the ER trip and hospital stay was $0 because I was admitted.
123
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Re: Will California out-of-network physicians accept private pay from a Kaiser member?

Post by 123 »

msj16 wrote: Wed Jun 09, 2021 5:14 am ...We are relocating to California. One family member may have to be enrolled in a research study only available at a Kaiser facility. That means that the whole family may have to enroll in Kaiser Permanente member plan although we have always had a PPO and liberally saw out of network doctors...
Depending on the family member involved (parent or child) you may want to explore an alternative. Perhaps they can have an individual plan with Kaiser (self-pay) while the rest of the family goes about with their PPO. This option may not work if the PPO coverage is based on the work connection of the individual in the research study (unless they can get some kind of dual-coverage with a separate self-pay).

Kaiser coverage is very good in California. I have heard they have over 40% of the population in the state enrolled under their plans. As such a large provider of healthcare they provide most services but there are specialized cases where they send members to other hospitals for rare surgeries as well as some transplants.
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Katietsu
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Re: Will California out-of-network physicians accept private pay from a Kaiser member?

Post by Katietsu »

I guess my concern would be the when and why you would want to seek coverage outside of Kaiser. Kaiser in CA has a great reputation for ease of dealing with routine care, including specialty care. Not on CA or with Kaiser, but, the time I might want out of my network would instead be a life threatening situation with a significant 6 digit cost.

To answer your original question, as long as you paid up front you could see a specialist in my area. I do not know about the usefulness of a per visit cost number since that would vary quite a bit based on exam complexity and specialty. With a PPO, I would think you should be able to look at the EOBs for your past visits and see what your current doctors have billed before the insurance negotiated discount is applied.

I agree with the suggestion of at least looking into the cost of getting the one family member their own Kaiser policy.
CedarWaxWing
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Re: Will California out-of-network physicians accept private pay from a Kaiser member?

Post by CedarWaxWing »

supalong52 wrote: Wed Jun 09, 2021 10:26 am
quantAndHold wrote: Wed Jun 09, 2021 10:05 am If you’re relocating and have to choose new docs anyway, why would you not just use Kaiser docs? Kaiser is quite good.
I would say Kaiser is very good for primary care, but if you need a specialist then you might want to look elsewhere. A family member required brain surgery and the Kaiser doctor suggested taking out the entire lobe tip. We got a second opinion and the head of vascular neurosurgery at UCSF shook his head and said their techniques were downright primitive. They switched out of Kaiser during open enrollment so they could get the surgery elsewhere.

On the other end of the spectrum, I was also on Kaiser for a year or two and had to stay in the hospital. My total out of pocket expense for the ER trip and hospital stay was $0 because I was admitted.
1+

I am retired from medicine, and had a spouse who was employed by Kaiser. Kaiser is very good at preventative and primary care. In regards to specialty services, it is hit and miss. Case in point (I have many): A surgeon I know, who was for years employed by Kaiser, needed an abdominal tumor. The best way to do so was was by laparoscopic methods, which could have been done in any other major hospital where we lived. Kaiser could not do it... which is fine... but they also refused to refer that surgeon to any other place that could do it and had expert teams to do it that way. The patient (surgeon) had to self refer to one of the other surgeons in town, and had to pay out of pocket to get it down the way it should be done. This was a particularly salty experience for that patient, because the primary care docs also missed the dx and the patient had to fight tooth hand nail to get the definitive tests done to clinch the diagnosis. That person STILL works for Kaiser... primarily because of the excellent retirement benefits... but still resents their refusal to send him out of the "system".
neowiser
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Re: Will California out-of-network physicians accept private pay from a Kaiser member?

Post by neowiser »

I've had Kaiser for years and have gone out-of-network several times for specialist consultations. Our premiums are so low at Kaiser that the money spent out-of-pocket is not a burden. A specialist consult at one of the University of California teaching hospitals can cost upwards of $500 depending on the physician. Kaiser performed the diagnostic testing (CT scan) recommended by the external specialist. I just had to show the order to my primary care physician. They are generally good about covering diagnostics and perform CTs, colonoscopies and MRIs with assembly line efficiency. Prescriptions written by non-Kaiser doctors can be filled at the Kaiser pharmacy.

You might want to consider a concierge practice as an add-on if cost is not an issue.
jmw
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Re: Will California out-of-network physicians accept private pay from a Kaiser member?

Post by jmw »

For non-routine specialty care and anything to do with mental health, stay away from Kaiser. Kaiser is great for routine (major and minor treatment) and primary care. That's all they're good for. If your health goes south in a non-routine and major way during the time you are away from the PPO, you will be in a world of hurt with Kaiser and possibly face 5 and 6 figure bills for non-covered OON procedures. Office visits of course you can pay cash. Kaiser says they will refer out-of-network when their own specialists can't do the job or go out of formulary when necessary, but that almost never happens. You will likely have to escalate to the state HMO/managed care agency to push an approval through, and that's if you have a decent Kaiser doc who will tell you about non-allowed treatments. Having access to PPO and OON is very valuable to keep as you get older.

Concierge doesn't work for this. Concierge is mostly high-end primary care for which Kaiser is an OK substitute for one year.

Can the single family member needing the research study get an ACA Kaiser plan? That's the direction I would go.
TMQ206
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Re: Will California out-of-network physicians accept private pay from a Kaiser member?

Post by TMQ206 »

Before making an insurance change, have you clarified with the study coordinator and your current insurer how expenses associated with the study are covered?

I’m no expert, but my very limited experience has been that clinical trials pay for the study treatment itself and some related care, and both the ACA and Medicare have rules about out of network coverage for approved clinical trials. Also, patients might have to be covered by the insurer for the care at the institution participating in the approved trial under ACA/Medicare rules if they have any form of out of network coverage.

So, the study coordinator and your insurer should be able to answer this if you haven’t already asked.
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Watty
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Re: Will California out-of-network physicians accept private pay from a Kaiser member?

Post by Watty »

You need to be very careful about assuming all PPO plans are good.

After I retired I used COBRA with a Blue Cross network. When COBRA was ending I needed to switch to an ACA plan and there was a Blue Cross ACA plan that looked like a logical choice.

The problem was that none of my Blue Cross COBRA doctors were in the in the network of doctors that the Blue Cross ACA plan used. In looking through the lists of doctors it was pretty clear that the Blue Cross ACA network was very limited and did not have the better doctors in it.
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celia
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Re: Will California out-of-network physicians accept private pay from a Kaiser member?

Post by celia »

Why not put the whole family in the PPO plan you want? I assume the Kaiser research study doesn’t cost you anything since you are providing data TO THEM. In the worst case, could the research patient have dual coverage, PPO and Kaiser?

To me this is like a Vet who is eligible for VA medical services and has another insurance through her employer (in case she’s in a car accident or something not related to the services received at the VA).

In other words, it would be like what you are already doing although you will now be in another state:
msj16 wrote: Wed Jun 09, 2021 5:14 am We are relocating to California. One family member may have to be enrolled in a research study only available at a Kaiser facility. That means that the whole family may have to enroll in Kaiser Permanente member plan although we have always had a PPO and liberally saw out of network doctors.
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BolderBoy
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Re: Will California out-of-network physicians accept private pay from a Kaiser member?

Post by BolderBoy »

To answer the subject question, sure - most any physician will accept private payments from Kaiser patients out of network. The price could be wicked so be sure to negotiate a cash payment deal.

Insofar as other comments about Kaiser, I would say that Kaiser is excellent for any issues that are within 1 standard deviation of the mean. Go outside that and the care proposed can be limited and/or dated. Kaiser works best for patients who are medically savvy themselves (MDs, RNs, etc).

Aren't Kaiser physicians bonused for keeping costs in check?

Disclaimer - I'm a Kaiser Medicare Advantage member.
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