Choosing to self pay

[somarco]

The "inflated" figures allow a bookkeeping write-down for uncompensated care.

Health care, especially in hospitals, involve cost shifting "magic" which allows providers to treat Medicaid and Medicare patients along with those who skip.

FWIW similar cost shifting occurs in other health related fields that are often not covered by insurance. Dental, vision, hearing loss, etc often have discounts for cash paying patients.

Laser vision services which are cosmetic, not medically necessary, have resulted in significant discounts from the original pricing. We have also seen significant improvements over the years.

When insurance, or government, pay for things the underlying prices become inflated. Most health care and educational tuition are prime examples.

 

[sman]

I'm a little confused . When I've seen insurance payments in the past they seem very low . The dr many times in an mri gets 1/3 to 1/4 of what he bills . I thought most of the time the insurance pre negotiated price was lower than the cash price an individual would pay . Why would a huge carrier doing billions of $'s of business pay more than a single person cash payer ? Has anyone ever negotiated paying cash for procedures with drs or hospitals ? Will the negotiate?

I assure you the cash price for an MRI at a free-standing facility (not a hospital) is less than the insurance negotiated price. I speak from personal experience here.

 

[C Ins Solutions]

I assure you the cash price for an MRI at a free-standing facility (not a hospital) is less than the insurance negotiated price. I speak from personal experience here.

Agree. Not only did Cigna deny my MRI prior auth prior to knee surgery but the cash rate was less than the insurance rate. I tell clients to take the script and go pay cash.

Carriers are denying MRI's on first request and requiring (in my case) physical therapy and steroidal injections before they would approve one. So I have an injured knee and before I can even determine the injury and significance of the injury, Cigna wants to me stress the knee in PT and/or mask the pain with steroids, before they'll approve a repricing for a $175 MRI.

 

[sman]

Agree. Not only did Cigna deny my MRI prior auth prior to knee surgery but the cash rate was less than the insurance rate. I tell clients to take the script and go pay cash.

Carriers are denying MRI's on first request and requiring (in my case) physical therapy and steroidal injections before they would approve one. So I have an injured knee and before I can even determine the injury and significance of the injury, Cigna wants to me stress the knee in PT and/or mask the pain with steroids, before they'll approve a repricing for a $175 MRI.

Nothing like the insurance company spending $1,000+ on PT and steroids to avoid a few hundred dollars on an MRI. The end result is likely an MRI anyway

 

[DonP]

I'm wondering what United's news means for 2026 plans . They obviously knew some of this news before they put their bids in 4-6 weeks ago . How does the increased funding from cms affect the bids versus the big increase in claims ? What about the crack down in fraudulent coding coming . How about the crack down in pbm's coming . So many cross currents . I have to think United's going to pull a Aetna and Humana and term a lot of county's and plans in 2026.That will cause an earthquake in mapd as there by far the biggest . If they decide to term 10% of there book at 1 mil plans . They said something very interesting in their earnings call . " It looks like we got a lot of the sick people that the other carriers termed" . When i asked my Humana rep in Aug why didn't they cross wall these plans they termed . His exact words were " They want these sicker members gone " United got them . I think much more no commission products in 2026 .

 

[somarco]

FWIW, there are some downsides to self pay vs running it through your insurance.

Self pay doesn't count towards your deductible or OOP.

Par providers that offer a discount for self pay may be in violation of their MCO agreement.

If your MRI (or other test) is one off it may be to your advantage to self pay. But if future claims are in the cards you may want to run it through your insurance . . . after all, you are paying a premium for coverage, might as well use it.

Self pay may or may not save money at the time of the procedure but don't expect a thank you card from your carrier.

I have an HDF plan with a $56 monthly premium. I got the plan 10 years ago when the premium was $55. My health has been good so far . . . most years I didn't satisfy my Part B deductible. In my worst year my deductible plus the coinsurance ran my OOP to around $800.

Rachel has regular G and would not have benefitted from the HD plan or self pay. The surgery she had last year had a self pay option that would have cost $8,000 vs $240.

YMMV

 

[scagnt83]

Self pay doesn't count towards your deductible or OOP.

Many carriers let you submit your self-pay claims to the carrier and it will count towards deductible. Its just a smaller amount and takes longer to satisfy the deductible and get any benefits from your plan.

 

[scagnt83]

I'm a little confused . When I've seen insurance payments in the past they seem very low . The dr many times in an mri gets 1/3 to 1/4 of what he bills . I thought most of the time the insurance pre negotiated price was lower than the cash price an individual would pay . Why would a huge carrier doing billions of $'s of business pay more than a single person cash payer ? Has anyone ever negotiated paying cash for procedures with drs or hospitals ? Will the negotiate?

Doctors bill insurers at the negotiated rate.

If you see doctors receiving less than what they bill, that is because they are billing Medicare/Medicaid directly. Or, they are billing higher than the negotiated rate in hopes of receiving more.

Cash prices are ALWAYS lower than the insurance negotiated rate. Its been like that for 20+ years. Especially for those on insurance under age 65. But very true for those on MAPD and Supps as well.

The provider has the claims process to deal with, and the overhead cost of filing the claim and communicating with the carrier. That is the "official" reason for the difference in price.

The unofficial reason..... insurers make more money when they approve higher costs of care... because it allows them to charge more in premiums... which provides them with a higher amount of net profits. (5% of a $1000 premium is a lot more than 5% of a $500 premium)

 

[Policy Monkey]

If you see doctors receiving less than what they bill, that is because they are billing Medicare/Medicaid directly. Or, they are billing higher than the negotiated rate in hopes of receiving more.

If a doctor bills at higher than the negotiated rate, then received less, can he write off that "loss" on taxes? If so, that could explain some things too.

 

[somarco]

If a doctor bills at higher than the negotiated rate, then received less, can he write off that "loss" on taxes?

That's a good question for the accountant

Many carriers let you submit your self-pay claims to the carrier and it will count towards deductible.

How many folks actually do that?

Are you referring to Medicare beneficiaries or others with commercial insurance?