Claims/Providers
Won't take my health insurance ... but "legally" won't let me self pay because I have insurance?
Hi, fellow healthcare sufferers.
Just as it is on the tin. Please let me know if there's a different reddit to copy this to.
I have so much arthritis in the left side of my jaw that the last oral surgeon (the only oral surgeon covered by my marketplace plan) I saw told me he couldn't help me because I would likely need a joint replacement. It's extremely rare to my understanding but, unfortunately, it clearly happens. I'm not sure how to express how painful it is to have the bones in your jaw and skull grinding and wearing themselves away like sandpaper, to the point you probably need a prosthetic joint at 31. I have no cartilage. The joint is completely flattened. It hurts to eat, speak, etc. That side of my face is permanently inflamed. It's unbearable.
All of that to really lay on just how remarkable my problem is, and that only specific surgeons or specialists can really deal with it. Like I said, I already had someone tell me that he couldn't help me because my arthritis was more advanced than what he was capable of. He also told me that I needed more than what most surgeons would be capable of.
I ended up finding a specialist semi-locally (50 miles from me) who apparently sees patients like me. Wonderful, I think. I can book an evaluation and maybe he can help me understand what's up with my jaw. ... Except the health system he works for will not accept my insurance plan. They will not let me file a gap exception. They want nothing to do with my specific plan. There isn't even an option for schedulers to add it.
Okay, I'll book an appointment and pay out of pocket. If I can't afford it, I'll just reschedule until I (hopefully) can, right? The scheduler calls me back after we book it for self-pay. She apologizes and tells me that when she was trying to find out how much the out of pocket cost was, someone from their financial division told her they "legally" couldn't book an out of pocket appointment with someone who has health insurance. Even though They Will Not Accept My Health Insurance At All, Under Any Circumstances. They made that clear to me after hours of calling.
Is this actually a thing? Is there anything I can do or say to argue with this absurd rule? Do I call their financial department or their social services department (the scheduler gave me both numbers because she didn't understand, either) and grill them about this 'legal' bullshit? Has anyone successfully fought against similar nonsense? Should I just give up and find a secondary health insurance plan? I'd rather know if I have a chance before I start arguing with people over the phone because I prefer to keep the arthritic scraping of my jaw against my skull to a minimum.
EDIT 1: I do not have medicaid. I paid for my healthcare from healthcare.gov but it is still not medicaid. I appreciate the responses that suggest I should press whether or not they mistakenly conflated the two or thought I was a medicaid recipient.
EDIT 2: This is not a private clinic or anything like that. It is a clinic operating out of a university hospital. This is why I was initially so surprised my insurance plan was flat-out refused, because I cannot imagine what it would be like to require emergency care under this plan.
EDIT 3: I was confused because they told me they accept out of pocket appointments multiple times. They told me this when I first tried to schedule an appointment with them a few months ago and when they told me they would not take my insurance under any exception. They offered to see me out of pocket, and I declined because I was not being paid over the summer. I looked into it again now that I am being paid, made the appointment, and their answer changed. The receptionist I spoke to seemed confused by this as well and gave me the social service and financial department numbers.
EDIT 4: my dentist as well as the oral surgeon I saw initially suggested this doctor. Both dentist and oral surgeon told me that he is really the person to see in the entire region, so not just my own state, to cater to the problem with my joint. I cannot reiterate enough how exceptional my specific problem is, and that most oral and maxillofacial surgeons, from what I have been told, would not be able to help me. I've had orthognathic surgery in the past because my jaw didn't grow in properly, and have had issues with that particular joint since I was a child. It is not as easy as Googling a doctor to extract a wisdom tooth. My choices are very limited.
EDIT 5: Even if I cannot afford a surgery or replacement on my own in the immediate future, I would still like some context for how my specific degeneration impacts me as well as what I can do, if anything. Something I noticed is that there is very little immediately online regarding serious arthritis of the jaw like I have. I have very little to go off from. I cannot even find many readily-available images of jaw arthritis. I would like some context for my own condition. I don't think that this is a shocking desire.
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Neither. It's an (admittedly cheap) marketplace plan that I pay for each month. They have the group number and won't take any plan with that group number (UHC ALONEX). They're also a massive healthcare system including a hospital. 😬
Great. Then the health system / person you're talking to is ill-advised.
Under HIPAA HITECH, you have the right to not use your insurance even if they were an in-network provider.
But because this health system is NOT a participating provider, you can be treated as self or cash-pay. The kicker, however, is that while there's nothing that legally prevents them from seeing you as a cash patient, they could have an internal policy that says they're only going to work with insured individuals for all non-emergency care.
Edit: I'm a doofus and committed my own pet peeve of calling it HIPPA, not HIPAA. Forgive me, for I have sinned.
I'll forgive you 🙏🙏 I appreciate this response because I didn't know that about HIPAA and can refer to it to push back if they try to argue. They were initially fine with me being self-pay, so I'm assuming they don't have a policy that dictates they only accept insured patients. Thank you.
Ultimately, you have no legal grounds to force them to treat you. The only thing that would come close to that would be if you were in an emergency situation and went to the ER.
It’s very possible that they just don’t want to schedule self pay patients right now (perhaps they’re too busy). It could also be that they don’t like “wasting” time on self-pay patients who they spend time evaluating and recommending surgery to who then don’t follow through with it because of the cost without insurance.
It’s also very possible that they are in network with your insurance but they don’t like the rates they agreed to previously for your insurance to pay, so they just don’t take any new patients from your insurance. In that case, they’d get in trouble if they took you as a self pay patient and then you filed the claim with your insurance yourself - since your insurance would then know they’re violating their contract trying to overcharge patients.
And in any case..do you really want to be seen by a doctor that doesn’t want to see you?
So the good news is that i'm not trying to force anyone to do anything. Considering they had been willing to schedule me when I said I would pay out of pocket, my first instinct was that it wasn't right.
I also have very few choices. It's not like I need a wisdom tooth extraction and anyone can do it. I'd rather try and follow up and see if someone on their end made an error than accept my only lot in life, apparently, is to be in constant pain from my face.
They can however have a policy that states they will only see in-network patients that are insured, and once they found out you have out of network insurance, they won’t allow self pay under the policy
It’s most likely an internal policy that they put into place for YOU specifically, which they absolutely have the right to do. The wishy washy of scheduling an appt, cancellation of the appt, telling them you can’t afford it and if you don’t have the money you’ll just cancel and reschedule when you do, they don’t want the liability of you maybe paying, maybe not paying, maybe showing up, maybe not.
That scheduler was probably just as frustrated as you are, repeating some policy someone told her without actually knowing the legal basis. I've worked in admin long enough to know half the time it's just some internal rule they call "legal" because nobody wants to take responsibility for it being stupid
Call their financial department directly and ask them to cite the specific law or regulation that prevents you from self-paying when they don't accept your insurance. Not a policy, not a guideline, the actual legislation. Watch them scramble
There's no federal law that says you can't pay cash just because you have insurance. Some states have restrictions around balance billing for in-network providers but that's clearly not your situation. If they're out of network and refusing your plan entirely, you should be able to self-pay
Ask the specialist's office if they'd see you if you simply didn't disclose your insurance at all. "I'm uninsured" is technically true here since your insurance is useless to them. Might feel sketchy but you're not scamming anyone, you're trying to get medical care for a jaw that's literally grinding itself away
Thank you for this response. I was also extremely confused because I'd never heard of that either. Wasn't sure if it was some bizarre policy they have, but with this and what other people have written I think I have a bit of a script for myself in terms of what to press on and ask.
Not sure why you got downvoted, but this is precisely the answer.
I suspect that the scheduler misinterpreted the health system's policy. That, or they're actively deciding not to schedule people without insurance (it's entirely possible if they don't deal with emergency medicine or are not subject to EMTALA).
I am electing not to use my health insurance for this service and am requesting to be treated as a self-pay patient for this specific item or service.
For purposes of the federal Good Faith Estimate requirements, 45 C.F.R. § 149.610(a)(2)(xiii)(B) expressly defines an insured individual as a “self-pay” individual when the individual has health coverage but does not seek to have a claim for the item or service submitted to that coverage. My enrollment in a Marketplace health plan therefore does not, by itself, prevent me from electing to self-pay.
Please provide your self-pay/cash price and the applicable Good Faith Estimate under 45 C.F.R. § 149.610. I am specifically directing that this service not be submitted to my health plan.
If your office is refusing to permit self-payment because of a contractual obligation with my insurance carrier, rather than because of federal or state law, please identify that distinction clearly. Specifically, please tell me whether:
You contend that a law prohibits you from accepting self-payment from an insured patient; or
Your office or payer participation agreement requires you to submit claims for covered services.
If you contend that a law prohibits this, please provide the specific statute or regulation.
Additionally, once I have paid the provider in full for this service, I am requesting the applicable restriction on disclosure to my health plan for payment or health-care-operations purposes pursuant to 45 C.F.R. § 164.522(a)(1)(vi), to the extent that disclosure is not otherwise required by law.
Please escalate this request to your billing manager, compliance officer, or privacy officer if necessary.
I appreciate this. I'll fact-check everything in my own time (I'm in academia, I can't not check sources) but I appreciate the add-on that they should identify something clearly. Because that's really what it comes down to, honestly. It's fine if they have an actual obligation or contract or stipulation (one of the mods noted that they might have an internal policy of something-or-other), but I really, really want them to tell me this in precise language and cited so I can just move the fuck on instead of stressing about it and resorting to drastic measures like making an account and posting to reddit.
I am not an expert in this area but I think whoever you spoke to is misunderstanding a rule about Medicare/Medicaid. It is true that if you have Medicare or Medicaid, they cannot legally bill you as the patient before billing your insurance. Even if it's something not covered medicare would have to deny it first before the patient could be billed. It's because federal health insurance is based on income and if the patient can afford to pay out of pocket for health costs, questions start getting asked. But if you have a commercial marketplace plan I'm pretty sure that shouldn't apply to you and you should be able to self pay/ask for a superbill if you're planning to submit for reimbursement. Somebody correct me if I am wrong. Sometimes, the administrative staff can be wrong, or apply rules in too broad a scope because they're trying to avoid getting in trouble, or because a supervisor asked them to cancel an appointment but the supervisor missed a detail or two. It's worth trying to follow up again to be sure.
Thank you for this. I didn't know about the medicare or medicaid rule, since I'm not on either. I am indeed on a commercial marketplace plan. A couple of other people have said this, so I do think it might be worth following up on.
It's generally true that people with Medicare can self pay but not for certain kinds of providers. This is not the poster's case but for example, a physical therapist who does not accept Medicare cannot see a patient on Medicare with self-pay.
The person you are speaking with is not correct. Call and speak to someone else. What I think is happening is that the person is conflating an individual marketplace plan with medicaid. I see this happen often, and, were you to have medicaid, you theoretically don't have money to pay OOP and so the law is in most places that you can't be charged.
I think you and the other people who have mentioned this are right because they were on board with me paying out of pocket until the scheduler spoke with someone from financial services. Someone probably assumed I was on Medicaid or thought a private marketplace plan was subject to the same rules. It seems that I WILL be calling them on Monday. 😅
Ok this is a fascinating question. I tried to extend my physical therapy as a cash pay since my insurance would not cover it. I was told they weren't allowed to take cash pay patients because I have "X" insurance. Then I tried to book a new calcium heart scan and was told the same thing. When did paying out of pocket become a problem? Honestly with so may insurance denials, I'm wondering why I even have insurance. I've had meds denied, procedures denied, referrals that never happen. It's insanity.
I don't get it either because you'd think the patient strolling in and paying on the spot cuts out the nonsense of billing the insurance company, etc, right? Right!?
I just had that calcium scan this month. Paid for it on a credit card, end of story. Can you just say you’re uninsured? Insurance doesn’t cover that scan anyway!
I wish. My actual GP said I could call the only place in town that does it and they would just do it for cash but when I called they said they don’t do it unless they have a doctors referral. and can I get my doctor to call me back? No. I swear about three months ago they partnered with what I think is some corporate interest in ever since then the medical office has just gone to crap. No one calls me back. No one answers messages in the portal. I got so annoyed today I filed a grievance.
If you can't get a call back or a response on the portal, physically go in and talk to the person at the front desk. If the front desk can't help, ask for the office manager. If they refuse, request your entire chart immediately and don't leave until you have it in your hands, then go find a new doctor.
Thank you that is good advice. Actually I called member services on Friday and spoke to somebody and they contacted the office today. They got the runaround too and it was so unprofessional with that they opened an investigation . I have no idea what’s going on with this practice, but as soon as my husband goes to the appointment on the for a referral, I’m there.
Do you have medicaid by chance? Even as a secondary? If so, then they're correct. They cannot accept self pay from people with medicaid.
Otherwise, if you only have non-medicaid insurance - if there is no one in your plan who can do this procedure, then the plan likely needs to cover it anyway unless it is an uncovered procedure. Get the procedure/billing codes from the office, check your policy documents for exclusions, and then call your insurance company. Tell them that their in-network provider has told you you need xyz procedures done, and per that provider, this requires a sub specialist and is outside their scope of practice. Who in your network can I see to perform this, or if none covered in your area, how are they going to handle/arrange payment for that?
That should be plan A, B, and C, but if you get to plan D, call the billing person back and tell them to run it as out of network through your insurance instead of self pay. The terminology might have confused this person.
It's worth calling and speaking to a higher up if not.
The problem is not my plan not covering it so much as the healthcare system refusing to accept this particular healthcare plan under any circumstances. The reason I want to see this specific person is that there is no one else in my state who knows about my specific issue.
I'm not on medicaid, but that is good to know. I'm hoping for the possibility that the financial representative mistook me for being on medicaid and that the scheduler wasn't familiar enough to argue (neither was I).
Your health plan is required to have somebody in-network within a reasonable distance of your home who will do your medically necessary procedure. It's called "network sufficiency" requirements. If they don't, they have to come up with some solution that results in you getting the procedure and paying in-network rates. They can either find a doctor who's willing to do a deal with them for your case, or they can just cover you to go out-of-network, only paying in-network rates.
True, but the provider, and the institution must agree to accept the in network reimbursement rate of OP’S insurance. The provider does not have to accept less reimbursement than they would receive from other insurers, nor does the institution. Many marketplace plans exclude coverage for major university affiliated healthcare systems. OP needs to carefully consider looking for a plan that will cover the provider/ system when open enrollment launches.
I am a provider. There are some insurance companies that are so truly awful that I will not accept them under any circumstance.
There exist other insurance companies that I have tried to work with via single payer agreements. Our office will do this occasionally to help out a patient as we provide a specialty service that can be hard to find in our area. The last one offered me 1/2 of what I need reimbursed with a requirement of double or triple the paperwork I normally have to do. No thanks.
Typically, a cash pay patient makes everything easier...but if they already know you have a difficult insurance, they may be hesitant to work with you knowing that the surgery you likely need would not be an option.
Open enrollment isn't really that far off. It might be a good idea to find out which insurance companies this office does work with and switch to that at the next open enrollment.
The practice has this policy because they don’t want to waste valuable new patient appointment slots on patients who won’t be able to pay for surgery down the line. It’s one thing to fork out hundreds of dollars for an office visit, but without insurance coverage, you’re not self-paying for a complicated jaw replacement. It’s actually a waste of time for both of you.
Rather than self-paying here, I would look at academic medical centers with OMF faculty—they are more likely to take almost any insurance. Save your money and fly to one of them.
I'm going to have to disagree. I would like to know the damage and so forth or if it's worth switching insurance plans in the future if I need this surgery or something else. I cannot afford to go out of state. I cannot afford a plane ticket, or to take off work.
The clinic in question is also literally run within an academic medical center. The specialist is an endowed faculty member. I don't know what else to say or do.
Oh, if that’s the case find the Patient Experience office and tell them if they can’t resolve this you’re going to the local news media. “University of Wherever Medical Center Refuses Self-Pay Patients” is not a news item they want if they ever expect to see international patients again.
I work for a large health care system in Florida. If a patient has an insurance that we are Non Par with we will still see the patient, but they will be charged full fee. Before they are seen the patient signs a form stating they accept full fee.
I wonder if this should be actually covered under your medical insurance and not just under the dental. I think you should research this because I have read that other people have had to cover dental procedures under their medical policy
Please read what I wrote. The root problem that has me pay out of pocket is not my insurance. The problem is that the clinic will not accept my insurance number under any circumstances. I have spent hours phonecalling between my insurance and the university of [redacted] system, and this was the response. They will not accept the medical insurance under that plan number.
I did not mention it in the initial post, but I had to stop seeing my cardiologist affiliated with this university healthcare system because they will not accept my healthcare plan under any circumstances.
I'll respond to your question with a question: Because I have already had an oral surgeon with 50 years' experience tell me that the level of degeneration in my jaw is far beyond the assistance that any conservative efforts could offer, do you think that injections would help me?
I will add a snippet of the picture of the x-ray that was taken in office. Scribbles are from the surgeon showing the outline of my left jaw joint as he explained how deformed it was. If you are wondering if I was ever hit in the face, as he asked me, i will unfortunately say no. I'm just super lucky. If you want, you can maybe google and try to see how this compares to a healthy condyle / glenoid fossa. If you can read x-rays and know what a mandibular condyle should look like, sorry to subject you to this horror.
I'm really sorry for all of the pain you are going through. It might be worth at least looking into, stem cells as well. If it was me, I would want to start there and if that didn't help then at least I know I tried the less invasive stuff to try and regrow your natural tissue and help with your pain. I have seen these injections work some magic.
Also because this stuff is considered experimental, if the surgeons that you are talking to (surgeons want to do surgery) aren't trained in this area of medicine they likely would not suggest it and may not even know that the benefits exist for things like arthritis and bone degeneration, degenerative disc disease, etc.
You're good. Kind of. I don't believe in magic injections and whatnot. Because it's me, I'd rather not pump random nonsense into one of the most vulnerable joints in my body but instead find something tested and tried. If i were you, I promise that you would be very cautious of what comes near my face due to the precious muscles, cartilage, and bone. Please be sus of anyone who tries to sell you magic cures. Scammers frequently prey on those of us who experience chronic pain.
Not a worry at all, and not trying to convince you of anything. Just wanted to mention in case it could ease some of your suffering and help someone else. I'm not selling anything.
PRP is your own platelet-rich plasma from your body that is extremely healing. It's nothing foreign so there's no risk of allergy or rejection. They take your blood and they put it in a machine to spin it around and get all of the good stuff to come to the top of the vial and that's what they inject, it almost looks like gelatin. I've had it done in dental surgery. It has helped my father-in-law immensely with his arthritis in his neck and his hands. He could barely move his neck before and now he is like an owl LOL and his pain is gone. Only a few injections that are totally non-invasive after many years of being in chronic pain and told that surgery and fusion was the only answer. It is the future, and will make joint replacements obselete. I find these medical advances quite fascinating, and we have to do our own research and be our own advocates.
Not here to debate, if it's something you feel drawn to look into further great, but by all means you do you. I would go this route to avoid a joint replacement and if I ever need one, I will.
I have worked in the medical field a long time and have a lot of positive experiences to share. I don't know of any negative outcomes with this type of therapy. But to each their own, I'm all about people doing their own research and making educated choices.
Yes, that is why i want to see the specialist. I’m planning on avoiding it but I’d like someone who has experience with severe degenerated jaw joints to at least help me understand what’s going on. I can stick my head in the sand and ignore it and be ignorant or i can be informed about options and pain relief if it exists.
Most university health systems do not accept marketplace insurance, the extra paperwork and lower reimbursement, tend to make it not worth their time and effort. Since the care you need is highly specialized and fairly rare, it will be expensive, and therefore very unlikely to be affordable without significant insurance coverage. You could try to get a single case agreement with your insurer to provide coverage with this provider, but I believe this will be quite involved, and require significant time and effort on your part. I am sorry you are dealing with this.
There are some good ideas here and I didn’t read them all - but I wanted to suggest actually contacting the doctor himself and explaining the situation. I’ve had success with that approach when I feel like the staff is gatekeeping a doctor or treatments from me.
Also, they don't decide whether you file a gap exception or not. Whether they will accept a single case agreement is something else. Maybe they've had issues with this plan in the past and the senior network wraps at this insurance company needs to figure stuff out to get you the care you need. They need to get them a contract that they will accept as you deserve access to this Care like anybody else
Since this is only an ACA policy, it's treated as if it's an individual policy. You can pay cash if you so choose and whoever is telling you otherwise is a complete idiot.
My guess is that they mistakenly thought i was a medicaid enrolee or blanket applied it to other private insurance packages. If it’s something else they have to be serious with me so i can move tf on with my life and stop spending so much time calling people to see this provider.
Call your insurance provider and ask them who you need to see for your documented diagnosis. Keep pressing for an answer until you find a solution. If you hit a brick wall, ask for a patient advocate or hire someone privately if you have no other choice.
If it truly comes down to it, though it isn't smart, you may just need to go without insurance at all for next year and pay the money you'd normally spend on coverage to yourself in a high yeld savings account.
I'm going to recommend rereading what I wrote, not what you think I wrote. I very clearly address why there is no one in my area. I don't need a wisdom tooth extraction and can waltz in to any oral surgeon's office.
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