I have a primary care appointment every 3 months for a chronic condition.

[LuckyCharms]

My last appointment was due in March, which I canceled, and rescheduled to next week.

Since the time that I canceled, I received a message that my insurance will no longer cover telephone visits, and I must come in for the appointment.

I wrote back and asked if I could self pay for a telephone appointment, which I am having later today.

I received a phone call today from the primary care office that I can not self-pay for a telephone appointment, because that is considered to be insurance fraud. It was also clarified to me that the insurance will pay for today's telephone appointment, but beginning tomorrow (6/13/20), all appointments must be in person, or insurance won't pay them. So, you can't self-pay for a telephone visit ever if you have insurance, and after tomorrow, you must be seen in person, and it must be paid by insurance, if you have it.

None of this makes any sense to me.

[Throck]

1. Call your state attorney general's office.

My mom is in assisted living and they made calls to the insurance company. Problem fixed.

[still_one]

2. That is insane on both counts. They have intentionally setup a catch22 situation

What they are saying is they do not do video appointments.

Since it is a medical facility, they should be following proper safety protocols. Social distancing, requiring masks, and doing temperature checks, along with periodically checking the medical personal for Covid-19

Where I am they encourage people to do video visits

Very strange

[LuckyCharms]

3. Exactly. A Catch22...

I was also told there is "no need to be paranoid" because everyone there is healthy, and safety procedures are in place.

What a freaking mess.

[CountAllVotes]

5. I am in the same situation

I had a TeleMed appt. on April 30. They want me to appear in person on July 30 for a re-check/RX refills.

I called and asked them why no more TeleMed. They claimed the insurance would not pay for it. I checked into it with the insurance(s) and was told they WOULD pay for it.

Is this genocide or what?

I really do not care to go there as it is a crappy feces infested clinic which is simply not safe for a high-risk person with a compromised immune system/progressive neurological disease for which there is no cure or for that matter, ANYONE ELSE!

If I don't show up, medications won't be refilled and I guess they'll just let me die.

Given the way this whole shit show is going it may be a better option!

I am so sick of this bullshit!

Get rid of the likes of me and all the rest of the populace that is in the same sinking ship.

Is the writing not on the wall for us?

Who are you going to call? Who?

[LuckyCharms]

13. Same.

Just called insurance, and they WILL pay for it until the Gov says emergency is over. Primary care front office fed me a line of bullshit.

Hang tough...we'll get through.

[CountAllVotes]

16. hahaa!!! I just called too!

They rescheduled me for a TeleMed appt. a few days earlier and they said it was "going to be this way for the foreseeable future". The last bill was indeed paid in full!

Is this a WIN for the likes of me and you?

I hope so Lucky Charms, I really do!

[bottomofthehill]

4. I think you may be able to self pay

But not at the insurance negotiated price. If your visit is usually 350 dollars, the insurance company has negotiated the price down to 125 dollars, of that you pay a 25 dollar deductible And the insurance company pays 100 dollars.

If you want to self pay, you would be on the hook for the full 350.

You can tell them that you want to pay in full for a phone consultation and that you will submit to insurance. When they decline, you may be on the hook for the full amount or maybe the insurance negotiated rate, it gets expensive quick though.

[bluedye33139]

8. Quite often the negotiated insurance price is higher than the cash rate

The typical contract between an insurance company and a clinics specifically demands that the clinic bill at the negotiated rates, which bars them from giving the lower cash pay price to clients and patients with insurance.

There are some differences with Medicaid, for what it's worth, and the negotiated Medicaid rate is typically lower than other prices.

[Ms. Toad]

18. I have NEVER, through at least a dozen insurance companies

seen a lower cash price.

I review all my statements, which each include the uninsured (cash) price, before anywhere between 10% and 90% is whacked off for the insurance reduction.

Insurance companies typically negotiate below-cost payments. Providers have to make up for the difference by charging cash customers more (not less) than insurance.

[bluedye33139]

27. No, the lower cash rate is for uninsured patients paying out of pocket

A patient with insurance typically must pay the full rate out of pocket, as clinics sign an agreement with the insurance company that they will not give the discounted rate to an insured patient.

If you were to go through a hundred insurance plans in the next month, none of the insurance plans would offer you a cheaper rate if you pay out of pocket, no. That's not what I'm talking about, though.

Hospitals and clinics typically will reduce a bill for an uninsured patient paying out-of-pocket. Some people take advantage of the 2014 HIPAA rule which allowed them to go to a provider, pay out of pocket, and not allow the insurance company to know about it. This is borderline sketchy, but it is a way that someone with insurance can at times save money on certain medical interventions. Someone with a high deductible plan, for instance, if they are certain that they will never meet their deductible. However, if you conceal the out-of-pocket payment from the insurance company, the dollars will not count toward the deductible.

As I read over what I just wrote, I remember how much I hate insurance. If I didn't live by billing insurance companies, this stuff would all seem like nonsense to me.

[Ms. Toad]

28. That is not the normal practice.

There are two rates - the billed rate (which is also the cash rate) and the contract rate (or a contract rate for each insurance company).

You are billed the cash rate. If you have insurance, after they process it, the bill is reduced between 10% to 90% of the billed/cash rate, before calculating coinsurance.

We not only have the experience of millions of dollars of medical billls (literally), we also have experience in trying to negotate a cash payment in gaps between coverage, or when the provider drops the insurer (making us uninsured as to that provider). In those instances, multiple providers refused - point blank - to give us a discounted rate for cash - we were billed the full billed/cash rate (which was always substantially more than the discounted insurance rate).

That is a major reason for having insurance - not only does it pay a substantial part of the bill, the portion you pay for any procedure before you satisfy your deductible is the UCR (or similar names depending on the insurance company) which is ALWAYS less than the billed/cash rate.

[bluedye33139]

29. Again, I am specifically talking about the price for uninsured patients paying cash

No, it is not normal for a person to be uninsured and to be paying out-of-pocket.

I am not asserting that it is normal for patients to be without insurance.

I am not asserting that a patient with insurance will be given the same price that an uninsured patient paying out of pocket will receive.

I am not here to argue about this. However, it is a fact that if a person receives medical treatment and does not have insurance, the business office will reduce the price for them in almost every instance.

My local hospital, for instance, does this as part of their non-profit approach. It is literally a fact that the hospital two blocks from my home will discount a patient bill enormously if that patient does not have insurance and is paying cash.

I understand that insurance and medical payments are complex, but I also understand that I am correct about this.

I am not asserting that you yourself always had an option to pay less out of pocket.

[Ms. Toad]

30. In my experience, you are not correct.

As I expressly stated, my experience included (1) being between insurance (no insurance at all) and (2) being tied to providers who did not have a contract with my insurance provider (i.e. cash as to those providers because the provider has NO relationship with the insurance company, does not accept insurance reimbursement, and the insurance carrier has no provision for paying out of network claims).

The price quoted, even with express requests for cash discounts as an uninsured person, has always been the billed price - which is significantly higher than the discounted rate under an insurance contract.

[bluedye33139]

31. Your experience was different, absolutely

https://www.consumerreports.org/healthcare-costs/how-paying-your-doctor-in-cash-could-save-you-money/

It is not universally true that every single out-of-pocket cost is lower than the insurance billing rate. And I am not claiming that it is.

"A growing number of medical services, from MRIs to blood work to outpatient surgery, could cost you less—sometimes a lot less—if you pay the provider out of your own pocket and leave your insurer out of the picture."

You don't believe this. That's fine. I have no investment in what you believe, and in our discussion, I have ultimately concluded that you did not understand what I was saying.

For instance, when I said that I know for a fact that my local hospital will discount a cash paying customer's bill, you said no. Where do we go from here? We disagree. That's where we go. By the time that every statement I make is reflexively negated, what would be the point of going on?

My clinic, for instance, bills $120 an hour for psychotherapy, but a cash paying customer typically pays half of that. (We are required to bill at the full rate if they are paying to meet their deductible.) This is a fact. It is literally a fact. This is one reason why I am aware of this side of healthcare billing.

[Ms. Toad]

32. I know exactly what you are saying, so that conclusion, at a minimum, is incorrect.

Nor is my response a matter of reflexively discounting negating what you say. I indicated my experience is with literally millions of dollars in billed medical expenses, My daughter is billed over $200,000 every single year - since she was 18. She is now 29. Prior to that time, her costs were between $50,000 and $100,000 every year since she was 5. Some of these were when we were insured (by around a dozen different insurance companies), some when we were not. Every single bill we have received includes the billed (cash) rate. In every single case, it has been higher than the heavily discounted insurance rate. In those cases when were between insurance, or seeing a provider that does not accept insurance, in every single instance we were quoted the billed (cash) rate, and when we attempted to negotiate a lower cash price we were told it was impossible - even when we could tell them the amount that they needed to cover their costs (based on discounted insurance rates, which we often knew from at least 3 different insurance companies).

Psychotherapy is significantly different that physical medical care, or even psychiatry, partly because of the long-standing discrimination within insurance companies against providing coverage for mental health care. In that limited practice (or other such practices traditionally not covered - chiropracty, accupuncture, etc., and sometimes physical therapy there are discounts for uninsured patients because the businesses could not survive if they charged full price because (1) not enough insurance plans cover them to survive on insurance (alone or primrily) and (2) people who are not insured tend to not to be able to be able to pay full price. This is especially true when the traditionally uninsured treatment is not a one-and-done (like psychology). Ordinary people, seeking care insurance does not cover, typically cannot pay week or month after week or month month - so as a matter of survival (and likely also philosophical inclination) those limited corners of medical care have developed a practice of discounting for uninsured.

The only other discount for cash situations I have encountered are are for newer tests before they are covered by insurance. For example, there is a quick cash MRI being offered for breast care - as an example - because it is not yet covered by insurance. To pay for the specialized equipment needed to carry out the test they have to get people to use it - which won't happen if they charge typical MRI rates AND it is not covered by insurance. It's simply a matter of economics.

[zipplewrath]

34. Hate to interrupt

But I had a strange situation arise. I had a scheduled test and the insurance approval hadn't come through. I discussed with the provider paying cash and if the approval came through, they could reimburse me. No, they wouldn't do that. So I said I would just pay cash. They wouldn't allow that either because the cash/self pay rate was LOWER than what the insurance company would pay. Basically they wanted their money.

I've seen similar things with pharmaceuticals. Very low cost medications that cost less than what your insurance company charges.

[Ms. Toad]

35. That is the exact opposite of what has happened

in every one of the numerous instances in which I have encountered it.

(You're also talking about a different situation. You have insurance through an entity your provider has a contract with. Your provider has a contract with your provider. That contract prohibits them from charging you more than the contract rate for covered procedures. That same also requires that their insured clients aren't charged outside of the contract for "off-the-insurance-books" care. That's just the way the contract works.)

As for medications - with at least the last half-dozen of our insurance providers we get the cash price if it is lower than our insurance copay. In other words, we pay the cash price - capped by our copay. Many of our medications have prices ranging from less than a dollar to $25, since the actual cash price is below our copay.

[bluedye33139]

36. You literally just reflexively denied every point I touched.

I have no desire to be in conflict with you over this subject.

I have said repeatedly that your experience was different, that I was not talking about the entirety of medical care, that I was not instructing you that you were incorrect in your assessment of your statements and payment history.

I'm done. Thanks.

[Ms. Toad]

37. reflex automatic, without thought.

That is not what I'm did.

[bluedye33139]

38. Okay, you negated item by item every statement I have made

Even my statement that you have negated every statement that I have made.

[Aristus]

6. Sounds like your insurance company is a bunch of assholes.

I mean, more than usual for an insurance company.

Why are telemedicine visits not reimbursable?

I do telemedicine visits all the time. I document them just as much as an in-person visit. I even document how long the call lasted. We are able to prove that we had a billable encounter with our patients. Insurance needs to cough up.

[LuckyCharms]

15. Aristus, I just called the insurance company...

The visits are covered. There is some fuckery going on in the front office of my primary care. She made a statement..."even your doctor doesn't know about this..."

Telephone visit coming up in a few minutes. I will inform her about what is going on in the billing office...

Have a good day.

[Aristus]

17. You too. Thanks.

If you get hit with a big bill for the visit, I'm going to be extremely pissed on your behalf...

[Hortensis]

33. Glad to hear. I knew this would affect tens of millions if so.

As for the insurance company fuckery that didn't happen, it reminded me of a time in Los Angeles when it did.

SoCal is SO big. It's normal for people to drive hours one way to visit family and friends, to work, for entertainment, weekends with family at the beach, in the mountains, etc. So it literally hit the front pages when a major insurer announced it would only pay for emergency maternity care within 2 hours of home. Really?!!! Discriminate against pregnant women by trying to chain them to their homes for several months? That didn't last long at all.

[bluedye33139]

7. It is not fraud to pay out-of-pocket

Hipaa was revised in 2014 and the "pay out-of-pocket" option was added.

Anyone dealing with insurance and the medical system in this country has a right to pay out-of-pocket.

The only fraudulent dimension I can think of would be if you pay out of pocket and request the discount or reduction in price with any kind of hardship declaration. Or if you request the price that they have for uninsured patients paying out of pocket. Your statements must be true and you cannot misrepresent your situation, but I don't get the sense that you are attempting to conceal this. My assumption is that your medical chart has your insurance information, and I don't get the sense that you're pretending not to have insurance.

Also, insurance companies and clinics enter into an agreement that the clinic will bill the same price for cash services that they do to the insurance company. That often means that a person with insurance will pay a higher cash price for a service, whereas someone without insurance would be eligible for the lower price.

Long story short, you are doing nothing wrong and you absolutely are not in the wrong to be looking at this as an option.

I'm not a lawyer, but it seems to me that if the insurance company will not pay for telehealth, then there is no governing contract requiring the clinic to bill the Telehealth session at the higher rate.

I would run this by a lawyer or a medical advocacy board or request that the clinic give you their determination in writing so that you have something to go on.

You absolutely have a right to pay out-of-pocket for any medical service if you have insurance. HIPAA literally was rewritten to allow this.

[LuckyCharms]

14. Thank you for this info. I appreciate it.

[5X]

9. What they are really saing:

The insurance won't pay the clinic for telemed, or not enuf.

[CountAllVotes]

10. +1

Its all about money and no one has been going to these hell holes so they are running low on funds.

They want more and they'll do anything to get it which includes having high-risk individuals appear in person and get exposed to COVID-19!!

GENOCIDE for a dollar.

How despicable!

[LeftInTX]

11. Frustrating....

Try speaking to the "Administrator or Office Manager" at the doctor's office. You may even want to write a letter saying that you want to "Self Pay and will Pay in Full" and you do no want your insurance involved with the televisit. It can be tricky because the way your account is set up, your insurance is billed automatically, so it is a PITA for office to make an exception for one visit and allow "Self Pay". Keep in mind that if you "Self Pay" for one visit, then the next visit, they may also assume you are "Self Pay" and will not file with your insurance. Much of this bill insurance automatically is part of a federal law.

Sometimes the people you are speaking to about these things are low level and aren't the brightest bulbs...

https://www.aapc.com/discuss/threads/not-billing-to-an-insurance-carrier.65845/

[LuckyCharms]

20. Good link...thank you.

[davsand]

12. Can you do a Zoom meeting?

My doc has been keeping a tight watch on me lately too. When my recent visit was due, I set up a telehealth visit to avoid going into the clinic. They insisted on a video meeting rather than a phone call. I asked why the video was necessary since all we were doing was going over blood test results, and they told me my Blue Cross would cover a video conference but not a plain old phone call. I was a bit surprised about that one.

One a side note, that last blood test was done in the clinic drive through while I sat in the car! I had to have somebody drive me, but other than that, it was incredibly easy! I called the lab when I got there and a tech came out with a tray of supplies and did the blood draw! That was a huge improvement, IMO. I'm hoping that will continue once the health crisis has reduced!


Laura

[LuckyCharms]

19. Laura, thanks for the info...

I'm going to research the possibilities for getting labwork done that don't involve physically walking into a lab.

[Ms. Toad]

21. I had a telemed visit this morning

The concern my doctor has is not insurance, but regulations. Until COVID-19 there were extreme restrictions on telemed visits. She is hoping the eased restrictions will continue so that we can have next year's visit via computer as well.

Someone suggested, below, it might be office prefence - because the insurance company does not reimburse as much. I have one doctor who charges everything he can get away with - including having his nurse take my blood pressure and ask a few screening questions so they can charge me $25/visit for a lab test that, at the time, I was having several times a week. (My insurance covers the lab test for pennies.)

I went directly to the lab, had it covered for pennies. Not going to pay $25 per visit - especially several times a week - when I have coverage at pennies. (And, incidentally, the nurse gave me information in one of those visits that I had to pay for that could have caused a fatal bleed. Fortunately, I knew better than she did.)

[area51]

22. Yet another reason

why we need Medicare for All.

What about a public option?

[left-of-center2012]

23. My insurance pays, and encourages tele visits

Blue Cross Medicare Advantage HMO N.M.

[flying_wahini]

24. I agree, report this.

Criminal how they treat people.

[Horse with no Name]

25. something is not right

all insurance companies have relaxed the telehealth requirements, including Medicare and Aetna. They have relaxed it even further to cover telephone visits. There is discussion that those restrictions will be strengthened soon, but as of yet, they have not.
The only requirement is that your provider document that they are doing a telehealth appointment due to Covid.
I would call your insurance company for clarification.
Good luck!

[RobinA]

26. Generally Your Doctor

cannot accept self pay if you are insured. And yes, it is considered fraud. The reasoning is something that would only make sense to an insurance company, and I don’t remember the whole story because I ran into this head-scratcher a bunch of years ago and forget the details. But that part of what your doctor’s office said is true.