# Insurance to Self Pay



## amym (Jun 28, 2011)

We have a few patients that have a $10,000 deductible with their insurance.  After they find out what our self pay fees are, they want to stop filing insurance.   Is this appropriate and is there something we should have in that letter to make sure we are not breaching insurance contract?


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## mitchellde (Jun 28, 2011)

That is what happens when you have a different fee schedule for self pay.  No you cannot make them self pay when they and you have a contract with the payer.  Your self pay fee schedule should be the same as everyone else to avoid this problem.  You are making it more attractive for patients to drop their insurance.  A self pay patient has not had to suffer the financial impact of paying premiums, so why do you reward that by also allowing them a cheaper fee?


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## ithomas14 (Jun 28, 2011)

Yes, Debra is correct, you have to bill their insurance. Your patients know they have a very high deductible, they chose it, so that is their problem not yours. The bills need to go to their insurance to work that deductible down. Imagine that the patient pays $7,000 out of pocket for medical services. If those bills go to their insurance, they only need to pay $3,000 more before their medical bills are covered. If they don't file insurance and there is a major hospital bill, that $7,000 is lost and the full $10,000 is coming out of pocket for deductible. They are already paying premiums so they should use the insurance.


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## eescalante (Jul 18, 2011)

I disagree. The patient does not HAVE to use their insurance, just because they have it. The patient can opt to not use insurance and be self pay at any time. It is their choice. At our practice we have the patient sign a form indicating that he is choosing to not use insurance for the service in question and understands that this makes him fully responsible for the self-pay amount and we will not (now or in the future) file a claim to his insurance for that service. 

This is fully legal and in accord with the patient's contract with his insurance to do so.


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## btadlock1 (Jul 18, 2011)

eescalante said:


> I disagree. The patient does not HAVE to use their insurance, just because they have it. The patient can opt to not use insurance and be self pay at any time. It is their choice. At our practice we have the patient sign a form indicating that he is choosing to not use insurance for the service in question and understands that this makes him fully responsible for the self-pay amount and we will not (now or in the future) file a claim to his insurance for that service.
> 
> This is fully legal and in accord with the patient's contract with his insurance to do so.



If your self-pay rates are substantially lower than your contracted amounts, you're running the risk of violating your (the provider's) contract with the payer, regarding the amount you're allowed to bill their customers. It could even be misconstrued as a violation of the Anti-Kickback Statute - tread lightly. 
"the OIG warns that waivers of deductibles and copays implicate both the federal antikickback statute and statutory prohibitions against beneficiary inducements."
http://www.ober.com/publications/983-hospital-discounts-uninsured-patients

The patient *can* choose to pay self-pay when they have insurance; generally this is done to prevent the insurer from knowing about the procedure, and generally, they end up paying more than if they had used their insurance. High deductible plans serve primarily as a discount plan for regular services, and for catastrophic coverage - meaning that unless they have a major medical expense (accident requiring hospitalization, cancer, etc.), the only benefit to the plan, is that they're able to take advantage of the payer's contracted allowable amounts with the provider. In other words, it should still be cheaper for them to use their insurance, than to NOT use it - even if the price variance isn't that great. Personally, I'd recommend going ahead and filing the claim, even if it's not going to pay, just to take the amount for that visit off of the deductible. In the event that they do end up needing to use their insurance to its fullest capabilities, at least they won't be out of pocket quite as much as they would have, otherwise. (Instead of a full $10,000 deductible, maybe it's only $8,000, because they've met some of it already.)
You really need to know what the language of your contracts say, regarding the amount you're allowed to bill their beneficiaries, without filing a claim to them. If it seems like you're enticing people to come to your clinic for lower prices (especially if they're not in financial hardship), and people stop seeing the point in buying insurance coverage because of that, your clinic could end up in a mess. Hope that helps.


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## mitchellde (Jul 18, 2011)

well said Brandi!


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