Why Won’t Doctors Take Cash?

From time to time, I’ve sputtered at Lambert about the run-ins I have had with the medical-industrial complex. Lambert thought that a recent bout of issues were sufficiently bizarre that they merited a post. Perhaps they are specific to my oddball insurance set-up but even so, I never had this issue before: a surprising number of doctors refusing to accept cash (or more accurately, “self-pay”; I would use a credit card but the conversations that go pear-shaped never get that far) and insisting that they bill my insurer directly.

I will also give some theories as to why this might be occurring, although the most plausible doesn’t fit my fact set. Also keep in mind that I haven’t gone to new doctors or labs for a few years, so if there is some sort of underlying behavior shift, it might have started years back.

I have an ancient insurance policy, an old-fashioned “major medical” indemnity plan. “Ancient” means that what was a mediocre plan then is really good by today’s standards. It does not cover preventative services or tests save one physical and eye exam a calendar year. But its huge positive feature is that I am not in an HMO or PPO. I can see any doctor in the world, no gatekeeping. For instance, I submitted bills for medical services and tests during my two years in Australia, and all were paid.

My insurer, Cigna, has been pretty good by insurer standards, in that they only seem to hassle me every 4 years or so, for a few months. It always seems as if a beancounter has come up with a bright idea about how to mess with customers that is eventually dropped. However, the only way to really stress a policy is to have a surgery and sadly I need a hip replacement. Even though this is a super high success rate surgery, I have some complicating pre-existing conditions1 and I’m having trouble getting orthopedists to factor that into their thinking (this is a long-standing issue, orthopedists are trained to look at joints in isolation; I’ve been seeing them off and on since I could walk and generally not found them very helpful, which makes me leery about letting them cut me up). So I have been shopping for doctors. That has been made more complicated by my being in Alabama,. Even though we have the best med school in the South, and an orthopedics group with a national reputation, the Andrews Sports Medicine Center, I’m having trouble finding anyone local. So I am currently looking for assessments and diagnoses in New York and would travel to another city if a promising MD were there.

The Bizarre Doctor Rejection of Self Pay, aka Cash

Now to the main point, the bizarre increased resistance among doctors for “self pay”. I’ve always preferred to self pay (save for my thank God very very few ER visits) because I have better privacy rights, and for a lot of tests, the “cash” rate is no worse than, and often better than Cigna’s best negotiated rate.

As you’ll see, in none of these cases was intent to self pay about seeking a discount from the doctor and that wasn’t the basis for the staff resistance either.

My first case was in early 2020, when trying to see a doctor in NYC who was referred to me for his advanced non-surgical techniques for orthopedic issues. His staff would not book an appointment but kept insisting it was “illegal” (they kept repeating that word) for him to take payment from me and not my insurer.

I went another round with the MD’s staff who kept acting like I was the one who was nuts, or worse. I offered to have them call Cigna with me on the line, or call Cigna themselves.

I called Cigna and recorded the call. The Cigna rep was incredulous and I had to repeat the staff’s claim for her to comprehend their position. She was working hard to stay professional and not start laughing. She dutifully looked up my policy, and of course found no requirement to have the MD submit directly to Cigna (duh, I’d been doing the reverse for over two decades).

She then volunteered to look up the doctor’s policy with Cigna. She found that there was absolutely nothing in his policy requiring that he directly bill Cigna.

The rep even generously called in her supervisor to confirm all of that and put in the notes on my file.

It was only after I told the doctor’s office that I would forward this voicemail that they were willing to book an appointment (I’m not sure they listened to it). By then I had already booked his one new client day for that NYC trip. Two months later, when I called to reschedule, we literally went back to square zero and I had to spend another three weeks overcoming their cash phobia.

I wound up not seeing him. I came for my appointment at 10:00 AM. He kept me waiting 2 hours. I had other appointments, plus didn’t want my first session to be rushed due to him being so far behind, so I left.

In NYC, I have been seeing doctors at the Hospital for Special Surgery. It’s all about orthopedic issues and despite its name, has doctors who provide only non-surgical treatments as well as surgeons.

All the doctors there appear to be solo or small group practitioners. The first one I saw has his own billing staff. He referred me to two surgeons under the HSS umbrella.

One has a very nice staffer who wanted my insurance info before she booked an appointment. It took a bit of explanation and arm twisting but she finally agreed to not taking the details and letting me pay the day of the appointment (I offered to let them authorize a charge on my credit card; that was clearly not a solution to whatever her issue was).

The second had an assistant who was wound much tighter than I am (hard to do!) and was not willing to give me the appointment unless I sent a copy of my insurance card. She at first insisted the insurers required that. I told her even if that was true for most policies and even most Cigna policies, it wasn’t true for mine by virtue of it being so old. I offered to send her my recording of my call to Cigna confirming that.

She then switched gears and said the doctor could set whatever policy he wanted to and he only billed to insurers.2 She said she’d speak to the office manager, put me on hold for a bit, and came back with the same line.

I also tried to get an appointment with a doctor in Baltimore who has written papers on leg length differences as they affect hip replacements. He practices out of the University of Maryland Medical System.

I got a somewhat nicer version of the run-around. The first phone rep said they couldn’t book without my insurance information. I gave my long-winded explanation about my policy. I then got kicked up to a supervisor, who after more discussion, said she’d call Cigna to have them confirm I could self pay. However, it’s been a week and I have not heard back. Maybe she didn’t try or maybe the normal Cigna hold times were too much.

What Does This Oddity Portend?

Maybe this is just an odd run of luck, but more than half of the new doctors I’ve tried to see in the last eighteen months have hassled me about self pay, and some would not back down. I never never never had that happen before.

This can’t be about mistaking me for a Medicare patient (Medicare does not allow self pay for any Medicare covered service unless the doctor has opted entirely out of Medicare). It was clear from the get-go that my insurer was Cigna.

It could be that some doctors in big group practices have moved to this stance because they have been bought out by private equity and the private equity firm wants to control the interaction with the insurer for better rent extraction (both upcoding and having all the data about insurer reimbursement to put them on the best information footing possible when it comes time to renegotiate the policy). But at least two of the three doctors who resisted self pay were solo operators, so that doesn’t explain my experience.

Could it be software, that common MD packages make it difficult to process self pay patients?

Any other theories welcome.

A Final Question to Medical-Business-Savvy Readers

Why is it any of the doctor’s business who my insurer is? As indicated for the HSS doctors, I am highly confident that they all have or at least pre-Covid had patients from overseas, meaning no US insurer in the mix. So the odds appear very high that they don’t reject patients without insurance, at least for routine office visits. 3

Arguably the effort to force me to let a doctor bill to my policy directly is tortious interference. The flip side it’s probably a tenable position to say a doctor can insist in being paid any way he wants to. Although given that actual cash as legal tender is supposed to be valid payment for all debts, and NYC in particular has laws against retailers rejecting cash, I’m not sure this position would hold if it were challenged, not that I’m about to go that route.

So the question is whether it is viable to say I don’t have insurance and find a way to nevertheless get a medical claim form? I could argue my accountant requires it since I deduct my medical (true, I have an elaborate set up to accomplish that despite my teeny size as a business) and he wants full backup in case of an audit to substantiate that the treatment was not for a cosmetic procedure.


1 The reason for my wariness is that the big reason hip replacements need to be redone within a year is a leg length difference resulting from the operation. I already have more asymmetries than most people have, starting with my feet, and troublingly a functional leg length difference as a result of a bad fall that messed up my hip. But illogically, it is the damaged leg that is now functionally longer, which needs an explanation. A surgeon’s reflex would be to “level the hips” meaning cut the leg down (!!!) but if the functional leg length difference results from an asymptomatic injury in my back, that could really mess me up (and I have extremely high pain tolerance, so this is not at all a stretch as a theory).

I am having great difficulty finding a doctor that looks more at the entire structure. Orthopedists that deal with oncology patients seem the best bet…but many won’t book a non-oncology patient, even just for a consult.

2 This is clearly not true. Some HSS patients are from outside the US.

3 One of my private equity buddies some years back was trying to help the head of his firm get his wife into surgery at another top tier NYC hospital, Columbia Presbyterian, because the insurer was dragging its feet on pre-approving the procedure and they wanted it done pronto (aside, this is the sort of thing the New York State Department of Financial Services lives to straighten out, so I can’t figure out why they didn’t go this route). The buddy got a ton of resistance because the hospital argued that if she had a bad recovery, she could run up a $2 million bill. Even though the head of the firm regularly pulled down $100 million a year (no typo) they had trouble persuading the hospital he had more than enough ready cash to pay any bill.

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  1. taunger

    My guess? They all have policies on no shows, and although you offered to authorize a charge, you do not represent the ease and certainty of charging an ins co for a no show. Med offices are ridiculously protective of their time in that way, and although your alternative is reasonable, it does not fit their process, and therefore is unacceptable.

    1. Yves Smith Post author

      No, they can’t impose a no show charge with no advance disclosure and consent and none of them have said they do that. I would tell my insurer to reject any such charge; I’m pretty aggressive about disclosure and honest business dealings.

      Ironically, only my NYC chiropractor does and she does not take insurance, so she relies on her patients being willing to cough up (of course, she can refuse to rebook until they pay).

      1. Karen

        I understand that you weren’t trying to obtain a discount, but many self-pay patients are, which may have created a general backlash against the practice.

        Keeping medical records private seems increasingly difficult, cash pay or not. That is extremely worrisome.

        1. Carolinian

          My understanding is that non-profit hospitals and perhaps the doctors who work for them are required to negotiate cash pay discounts with uninsured patients in return for their government gimmes on property taxes etc. Some years back I had an accident without insurance and did just that.

          But it could be the ACA has changed things since theoretically everyone now is supposed to be on some form of insurance.

          1. Yves Smith Post author

            No, there are rafts of articles about the outrageous charges that uninsured patients face at hospitals. They don’t get discounts.

            However, the hospitals are required to accept all patients who present at an ER. That was one argument for ACA, that the Medicaid expansion would reduce poor people showing up for what amounted to routine care at the ER.

            So the cash prices are inflated to cover inability to collect from many.

  2. Karen

    It might have to do with the rising prevalence of health-sharing ministries, which encourage their clients to self-pay (to get lower cash rates) then reimburse them directly. The provider can get paid substantially more by insisting on going through the usual billing process. I am a member of one such organization, Liberty Healthshare, and observed the same phenomenon. That doesn’t explain all the aspects of your story, which is different, but it’s possible the “no-cash” policy is set from on high and the schedulers just aren’t interested in what your policy allows.

    1. Yves Smith Post author

      No this is absolutely not about asking the doctor to take less. This is completely about some sort of weird idea that they are required to bill the insurer.

      I neglected one issue, which is actually the polar opposite of your theory: the Cigna negotiated rate for MDs in its network is LOWER than the doctors’ cash rate. For my regular doctor who is in a Cigna PPO and some other PPOs, she literally gets half of her regular rate on my annual physical after Cigna messes with her. Her assistant used to bitch and moan about it since they’d have to issue a partial refund (I told them to keep the $ on file). It wasn’t so much about the money but the extra accounting entires.

      I was really bothered by Cigna screwing with my doctor this way, imposing a PPO discount her when I’m not in a PPO. I was perfectly happy to pay my 20% copay on her rack rate. I even wrote the famed New York Department of Financial Services to have them make Cigna stop cheating my doctors this way. I think the issue was over the head of the agent who reviewed my letter.

      Now having said that, in the last couple of years Cigna has stopped making my regular MD eat its PPO rate on my regular visits. But they still do go after my ophthalmologist and force a discount on him (his official prices are ludicrously high and I regard the information content of eye exams as sufficiently uninteresting that I’ve relented over the years and let them bill directly).

    2. CuriosityConcern

      I haven’t heard of health sharing ministries, but I was thinking something similar. Maybe the office thinks Yves is going to try to low ball them(like a lot less then they would get in payment they would get from insurance).
      On the other hand, maybe they know(via EHR?) Yves has the sweet old policy and want to bill it.
      I did read the post but I’m not certain if Yves is trying to negotiate self paying the surgeon for surgery, pre-op assessments or for both.
      At any rate, hope the hip gets fixed.

      1. Yves Smith Post author

        No, no, no, no, no. Please read the bloody post. I went to some trouble to lay it out.

        The issue with all the staffers was TOTALLY AND SOLELY about their mistaken belief that they “had” to bill the insurer and were not allowed to take direct payment.

        That is how Medicare works. It is a fraud under Medicare for a provider who takes Medicare to bill a patient for a Medicare covered service. It is perfectly OK for private insurers unless the patient is in a HMO or PPO and the insurer’s contract with the doctor requires that. This does not seem to be the case with most (any?) Cigna plans, but it seems likely other insurers are very different.

        And US hospitals ALWAYS charge ton more to cash patients. You would NEVER if you have insurance, pay for a hospital service (as opposed to doctor’s services at a private practice or outpatient clinic). You’d be charged a monster premium to the insurer’s rate for the service. I’m not talking patient’s co-pay. I’m taking total price. Hospital rates to cash patients are literally 3-10X what they BILL to insurers.

  3. fresno dan

    Long story short, a good number of doctors are a$$h*les.
    I suspect a good number of doctors have no idea of what they do should cost. Most of the doctors (particularly specialists) I have had over the last decade (and I have had a bunch because I have moved from Sacramento, to Redding, to Fresno) are part of group practices. I would imagine that the billing practices are part of the contract between the group and the individual physician. And that the billing practices are designed to prevent price transparency. Maybe one insurance company gets a good or fair deal, but the practice fights tooth and claw to prevent any one else finding out what their cash price is, lest a patient ask at another practice.
    What is the price of something someone buys from Amazon? I suspect there really isn’t one “price” – there is a process of charging. To me, our medical system is like Disneyland (and not just because its a Mickey Mouse operation) – insurance is just the entrance fee – once you get in, there is another world of charges for rides, attractions, and food…
    And not related, but I find it remarkable in the adjustments to the bill of what the insurance company won’t pay and that I am responsible for, how many are less than 1 dollar. It must be a money losing proposition to mail me a another bill (to be clear, I have already gotten a bill for my co-pay, co-insurance, deductible, general gouging charge, specific gouging addendum, etcetera, but the absolute holiest of holies has not been achieved, a completely correct amount charged) but by all the Marvel superheroes, they are going through their billing process.

    1. Yves Smith Post author

      As I said, at least two of these doctors are most assuredly NOT in group practices. And the one MD who is has an adminisphere that is willing to entertain it. My long conversation with the supervisor was entirely about their fear of getting in trouble with “the insurer”. My guess is some insurers must be bastards on this issue even if Cigna could care less.

      BTW my regular MD is also solo. This is still a pretty common format in NYC if you have a good practice.

      I find it astonishing that, like Cigna initially, readers are not wrapping their minds around my fact set as presented.

  4. Samuel Conner

    In the multi-physician practice in which my PCP works, he was the only person who accepted self-pay patients. I did not try to pay with cash, but I noticed that my check was scanned and returned to me. They didn’t have to make a physical run to a physical bank to deposit that, but would have to with physical cash. I believe this group is owned by some sort of investment firm, and I could imagine that they were tweaking processes to maximize the rents that the group produces.

    Two guesses — a) payments processing systems are discouraging cash or perhaps not configured to receive it at all and b) self-pay might be interpreted to be a social status marker that conveys the impression that the prospective patient might not be a fruitful cash generation entity in the future.

    That’s cynical, but my impression is that increasingly the provision of care to patients is not the point of the exercise, with money payment a practical necessity so that the system can function, so much as “provision of care” is simply the particular income generating modality of the business model.

  5. jackiebass

    I arrived at the same conclusion about doctors seeing things through tunnel vision. This is especially true of specialist.Often there is little or no communication between different doctors. They all seem to be only focused on why you are there to see them and are oblivious to your over all health. It gets me as a patient frustrated.

    1. SteveD

      Is it possible there is an income tax issue here? MD Bills Insurer at their “card rate” for the procedure, say $400, even though they have pre-negotiated $180 with insurer for reimbursement. Difference shows up as some sort of income-reducing item, like uncollectible debt or something, thus reducing taxable income for practice.

      1. Yves Smith Post author

        No, this is not correct and there’s not tax benefit. Even if the doctor declared $400 and then said, “Whoops, I didn’t get $220 of income I was supposed to” he winds up with the same net of $180.

  6. KCS

    1. I’ve got a lot of my care at Mayo Clinic, Rochester MN ever since I was a dermatology resident there. First class in every way. Cash [or credit card] on the barrelhead.

    2. The last 20 years of my career were devoted to patients who wanted Botox™, Juvéderm®, and laser treatments. We took in so much cash that I put in a drop safe [like in a 7-11]. Lots of my patients [for a variety of reasons] preferred to pay cash. Unfortunately, our bank eventually started charging us a percentage for handling the cash deposits, so cash was not that much more profitable than credit cards. And [being good Canadians] we declared every penny.

    1. flora

      That’s an interesting point. Several non-doctor and non-medical businesses in my town, places like sporting goods stores and clothing stores, started discouraging cash or stopped taking cash a few years ago. When I asked why I was told the banks wanted them to stop taking cash. Since the cc payment wasn’t absolutely required I still pay cash at these stores after some complaining on my part – as a long time customer – that I did not want to use my cc and preferred to pay cash. The reason was supposedly the banks didn’t want to handle cash and there were “too many bad checks.” (All of a sudden?) The banks could be behind this push to move away from cash.

        1. lyman alpha blob

          That would be my guess – it’s not the cash itself they’re opposed to, but the employees needed to handle it.

          All the banks have cash sorting machines which do not make mistakes* and can tally a large pile of cash in very short order. In my experience as a teller years ago, there were not that many bad checks as the bank took strong precautions against that. Not 100% certain, but I believe banks are insured against bad checks to an extent, just like they are for cash lost through robberies. That’s the reason tellers are trained not to resist at all during a robbery and why they will be fired if they do – the bank is insured against those types of losses providing basic rules are followed. But there’s no guarantee they won’t be sued by an injured party if someone gets hurt by an employee playing hero.

          Those pesky employees have all kinds of ways of cutting into the bankers’ maximum potential profit, better to be done with them.

          WAMU also experimented with low-employee branches, although I think they kept one or two manning a counter just in case. That was a little before getting caught being involved in egregious mortgage fraud and going spectacularly bankrupt.

          * I’m sure they’re not infallible, entropy being what it is.

      1. ambrit

        The “handling charge” imposed on top of Credit and Debit cards by the card issues, of which, I am assured, the bank receives a portion, could be a main reason for trying to move ‘away from cash.’
        For example, the local County adds a 2 1/2% surcharge to all card payments, such as for taxes or auto license plates, because, as the placard advertises, the banks charge them that percentage on all transactions. Cash negates this percentage. Personal cheques are not taken any more.
        On a more conspirational note, the issue of “Total Informational Domination” would be an issue. Imagine all of the, not only, metadata, but person specific data to be ‘mined’ from the plethora of card transactions. A proper Panopticon optimized governmental economic social system would become the real world embodiment of any and all fictional Dystopias.
        Circling back to Yves’ example; this hesitancy on the part of lower and even mid-level medical functionaries to accept cash payments could be driven from above. The ultimate motivation for such policies could have little to do with the financial aspects of the interactions, but some twisted concept of ‘social control.’
        Well, that’s one jaded cynic’s take on it.

    2. hoonose

      Many fully elective and optional medical treatments like this and Lasik eye surgery are more easily cash/free marketed like a more normal business. Especially in the outpatient setting. These procedures are typically less risky and complicated. And more easily priced out in cash.

    3. Keith Newman

      I have a friend who was a Member of Parliament in Canada. As you say, KCS, he preferred donations by credit card because the bank charged so much to process cash (don’t know the actual numbers).

      Yves, I think you need a NC reader who’s a doctor to tell you what’s going on. IMDoc maybe?

  7. Michael Cooper

    I have noticed this for years. I don’t think there is much more going on than the doctors don’t want patients to see what the full bill is, as opposed to the copay or co-insurance amounts that the insurers eventually bill the patients. The staff are trained to be bulldogs about it.

    1. Yves Smith Post author

      Cigna show it all on its Explanation of Benefits, the official rate, their discount if they are forcing a PPO discount on the doctor/lab (I think they call it “adjustment”) and the patient obligation. It’s all there. Cigna wants the patient to see what a great deal they are getting by being with Cigna so they make a point of showing the undiscounted amount. In other words, these doctors are clueless if they think patients don’t see their rates.

      I believe it’s totally different with Medicare, where all my mother sees is the co-pay, so if they take Medicare and private insurance, they may have gotten the wrong idea from Medicare.

      1. Tom Doak

        I have seen the same “retail price” and “adjustment” on my insurance bills But it never occurred to me until your description that maybe insurance companies are showing us a made-up retail price to exaggerate what they are “saving” us, and that’s not what the doctor actually charges anybody.

        [If the doctor does all business through insurance companies, then he really DOESN’T charge anyone the retail price.]

        In that case neither doctor nor insurance company would want you to discover the real price.

        1. Yves Smith Post author

          No, it’s not made up. As a patient, I can tell you that when I pay at the time of service, which is almost all the time, it is the undiscounted rate. That is the actual rate.

          It would be some sort of fraud for Cigna to show a rate for the MD that was bogus. They can’t make up prices for the doctor’s services.

          1. Sue inSoCal

            Yves, I’m so very sorry about your hip and the complications. ! (Btw, what is up with oncology refusing to see a patient unless they’re a present cancer patient, but past cancer is a complication? Smh.)

            I was going to write more about the (usual but not always) non-profit write-off scam, which impacts cash pay, but the YouTube above regarding hospitals hits it on the head. Medical offices use these systems also.

            It’s been many years since I worked in the medical/legal industry. In analyzing medical bills for work and for myself in the last decade, I note that the system is, like many others, designed to throw money at the business poo-bahs at the top of the pyramid, and cut staff short. That said, with a classic “major medical” plan, there’s no legal justification that should preclude you from paying cash that I can think of. The medical office billing people should know what your coverage means!

      2. ambrit

        Curious about your Mother not seeing the undiscounted rate.
        On Phyl’s quarterly Medicare “explanation of charges” mailing, the costs are presented as “original” bill, less “adjustments,” netting out with the co-pay amounts.
        Good luck with our “Bestest In The World” (as measured by world per capita expenditures, [the neo-liberal ‘gold’ standard,]) medical ‘access’ system.

        1. flora

          And, again, to go on too long (sorry) about the difference between traditional Medicare and Medicare (so called) Advantage (so-called) plans: If Yves’ Mother has a Medicare Advantage plan this could explain the difference in billings, imo. Traditional Medicare has a fixed cost reimbursment rates and straight forward summaries mailed to enrollees; the so-called Advantage Plans – private insurance HMOs or private insurance PPOs – do not.

        2. Yves Smith Post author

          She does see the full price on her drugs and ambulance charges but not on the MD visits. She’s in a Medicare Aadvantage plan, so maybe this is the result of being in an HMO.

          1. ambrit

            Ah. Classical Neo-liberalism. Different ‘rules’ for different ‘classes’ of coverage.
            Reading this thread, and some comments in Links, has convinced me to stay as far away from Medicare Advantage Plans as humanly possible.

    2. hoonose

      As a now retired internist I might be able to tell you a bit.
      Most docs don’t know all the costs, all the relative values and pricing of most things more complex than simple tests or procedures. Especially if the hospital is involved.
      As the procedure gets more complicated, the pricing gets more difficult. For instance other docs or mid levels, consultants or assistants, may be involved along the way, in or outpatient. More testings and treatments may be needed, not easily identified at the start. Especially if the patient is high risk. The higher the risk, the more potential for complications and/or a longer hospitalization and/or recovery period needed and attended to by the doc(s).

  8. TMoney

    Early on in America, I realized as a new immigrant I had “no preexisting conditions” – because I had no medical records. Medical Tabula Rasa. It is only when you go to the doctor that insurance companies know what you have and that doctors are required to turn over your medical records to them. Paying cash without a social security number allows you hide medical conditions. I suspect insurance companies strongly discourage this sort of thing. This was important when preexisting conditions where excluded from insurance. It still is if your rate depends on preexisting conditions.

    Cash, alas is only good once you’ve had treatment – because you have a debt. They can not refuse debt payment in dead presidents. They can refuse to let you go into debt. I’ve often wondered about tendering cash at a no-cash bar with my (now cancelled) credit card. *

    video on* If I offer cash and they refuse is the debt settled ? *video off*

    1. Yves Smith Post author

      As indicated, I have a >30 year old policy, so Cigna has seen all of my diagnosis and procedure codes, but not any medical records. And aside from my busted up hip and occasional injuries before that, I’m healthy as a horse.

      And as indicated, I am using “cash” metaphorically. I always pay by credit card and if need be, they could authorize an expected visit amount in advance.

      I see dentists all the time (pre-fluoridation teeth :-(). Dentists don’t often have patients with insurance. And a visit to a dentist (if you need a crown) or a endodontist or an oral surgeon is regularly higher than a routine MD office visit or even a physical, yet I’ve never seen dentists ask intrusive questions about ability to pay.

      1. TMoney

        I’ve had similar experiences “shopping” trying to get a price for a procedure. High deductibles make a case for skipping insurance and getting a cash price – especially for out of network stuff, but heard the same “we don’t take cash”/”we only bill insurance” stuff as you.

        The only plus side is it does allow give you leverage when talking to people who waffle about “free market” medicine**, because clearly there is no way to get a “competitive price” when you can’t get ANY sort of price.

        I know that the Surgery Center of Oklahoma post cash only prices.I don’t think they even do 3rd party billing.

        ** Such people tend to be young and have never been to the doctor for more than a cold.

        1. Yves Smith Post author

          As I indicated, I’m not attempting to get a discount and no one who is giving me a hard time is taking it that way. I say I want to self pay because my privacy rights are better. Clinical and imaging labs give big discounts and you don’t have to ask.

          And you can’t negotiate discounts on surgeries. The hospital controls the staffing. Unless its some minimally invasive procedure done by an MD in his office with local and his own nurse, you have zero control.

          Aside from the surgeon, they can put any damned other person on your team the day of the procedure and you have no say. I’ve had readers tell me of obvious staffing featherbedding (MDs who were in the OR on the bill who were clearly superfluous) and they could do absolutely nothing, because they guy was actually there.

          1. TMoney

            Sorry, I wasn’t suggesting it was about a discount, I literally couldn’t get a price (let alone negotiate a better one). The reason (I was given) I couldn’t get a price was because they wouldn’t bill just me, they had to have a 3rd party payer. In essence I was being forced to “use” my insurance. I did manage to get the hospitals to tell me the price my insurance was “going to pay” when I stumbled on some magic phrasing that triggered a change in the script. But my deductible was so high I was on the hook for the whole thing – so I cared about the cost and in my naivety when I started, I just asked for “a price” so I could compare with other local providers.

            On featherbedding: you can’t even put a sign on your body saying — out of network doctors don’t treat me ! You sign that right away when you agree to treatment – I read the terms of service before I went under the knife. My current insurance tends to tie tightly to the hospitals so this isn’t an issue, but the clause was in the paperwork suggesting not everyone is so lucky.

            The anecdotes posted here suggest LOTS of people have these issues or variations.

            1. Objective Ace

              I’ve been know to cross out and initial things I dont like in the terms and conditions. Entry level employees often run it by their managers, but they more often than not let me do it

        2. hoonose

          Good points. Young and healthy uncomplicated patients are easier to price out and go closer to more normal free market pricing. Less chance of complications, shorter hospitalization and recovery times. Older and more complicated patients with multiple pre-exisiting conditions can much more easily encounter the need for further testing, treatments or consultants. Or a complication that can all add significantly to the overall costs and time involved. In and outpatient.

  9. SE

    Although your insurance contract says you can pay cash, the “proprietary” insurance contract (for participating doctors) typically requires that they bill the insurer directly. Those same contracts often base some payments on the self-pay price offered to patients (plus an additional discount). Hence, when doctors routinely discount self-pay patients 30%, insurer payments for other/all patients may also decrease 30% or more. Some primary care doctors can develop concierge practices which bypass these policies, selling extra access, or they can refuse to participate with insurance altogether. Orthopedists, whose income relies more on pricier surgery, therapies or MRI’s, with dramatically higher expenses, usually must participate with insurance to make ends meet. Few orthopedists can practice without also signing “proprietary” hospital privilege contracts, that may have problematic policies regarding self pay patients (often related to unpaid emergency coverage mandates).

    1. Yves Smith Post author

      While this may be generally true, you are missing the key point: those MD contracts are network specific. You used the term “participating doctors”. This is participating in particular networks. For instance, most insurers offer some sort of Medicare B plan. Many doctors in big cities do not take Medicare and make new patients sign waivers acknowledging that they don’t accept Medicare. So if a patient, say in an Anthem plan through his employer turned 65, and he wanted to keep seeing the same doctor and happened to get an Anthem Medicare plan, too bad, so sad, doctor won’t take it.

      To put it differently, doctors participate in particular patient plans, HMOs or PPOs.

      I am not in any of those plans. I am in an indemnity plan. No network.

      As indicated, Cigna tried forcing its network discounts on some doctors even though this defrauding the doctor. Cigna quit doing that with my regular MD a few years back. I suspect someone in the NY Department of Financial Services realized this was happening and told some (all?) NY insurers to cut it out. I’m in a NY state regulated plan.

  10. Cocomaan

    Could it be software, that common MD packages make it difficult to process self pay patients?

    This is my guess. I’m not in healthcare but I am finding that organizations with various CRMs increasingly cannot do anything remotely out of the ordinary.

    Back in the days of paper, you could just hand write a note in the corner about the exception to the rule. Not anymore. We are becoming trapped by our own software limitations.

    Not to mention that many of this generations software is built on the back of last gen software that was just as clunky.

    1. QuicksilverMessenger

      I’m having trouble wrapping my head around this though. My daughter broke her elbow on the school playground a few years ago. Insurance paid for most of it, but there were some extra costs that the hospital billed me directly (this is a large, well-known Seattle hospital group).
      And I simply went to their website, to the bill pay, put my credit card info in, and done. Very easy to set this up. That is, if they wanted to take ‘cash’ payment, they could.

      1. Yves Smith Post author

        Yes, they are all set up to process the co-pay portions.They all have some sort of merchant account to take debit and credit cards.

  11. Gregorio

    I went to a doctor for a minor procedure, I told the doctor’s office that I had just recently signed up for my current insurance policy, and that this would not be covered because it was a pre-existing condition, yet they insisted that they should run it through my insurance (this was pre-ACA) and let them make the determination. I stupidly acquiesced, upon which the insurance company promptly cancelled my policy because I had not disclosed a pre-existing condition, even though it was not something that was medically necessary to treat, but a minor annoyance that I had electively chosen to address.

      1. Arizona Slim

        Something similar happened to me. Insurance company conflated two things in my medical records that had nothing to do with each other. Company cancelled my policy on the grounds that I hadn’t disclosed a pre-existing condition. However, that condition had nothing to do with why I went to that particular doctor.

        Since then, I have been very careful about what I say to doctors. I just don’t trust them.

        Ditto for insurance companies.

  12. JH

    I’m guessing they have policies for how to deal with each insurer they are contracted with. When they hear “Cigna” they assume you have a typical network-based PPO or HDHP plan and want to go through their normal process of billing insurance and getting their contracted rate.

    You should try telling them you have an obscure insurance plan from another state/country and want to self-pay, and get a “super bill” so you can submit to the insurance yourself.

    Alternative I don’t think there’s any legal issues to say you don’t have insurance. They may be concerns about ability to pay especially if progressing to surgery, but you could say you’re very wealth and will pre-pay.

  13. Solideco

    I wonder if an aspect of this is that the office staff has been through training classes from the insurance companies or the firms that provide the billing software. I’m sure the classes cover Medicare and can imagine that the Medicare exception on cash payments is generalized for all insurance providers.

    Regardless, I find it easily to believe that somehow in the medical office social consensus, “from Medicare” was drop “cash payments from Medicare patients is prohibited.”

    1. Jeff N

      Yes, I am thinking that, certain office staff, when confronted with a task they don’t know how to do, simply put it aside and hope it goes away or someone else in the office takes the request.

      Another possibility is that the older, more experienced staff (60 or older) than could retire, retired when COVID hit. My 70 year old mom was doctor office staff and she begrudgingly retired in March or April last year.

  14. Keith

    I had a similar experience in Houston around 2007 to 2008ish for a GI doc. I don’t recall all the details, but I had a high deductible policy at the time and so wanted to pay cash for ease, otherwise the bill would come a couple of weeks later. The staff told me point blank that they were not equipped to handle the transactions, they had a service for that. The GI doc ran his practice with his wife ( not sure of her practice).

  15. James Simpson

    What’s this about paying a doctor? Is it a strange joke? Here in the UK, I’ve never been asked to pay any more than the prescription fee – as I live on Universal Credit, that’s waived. Who’d have thought of it? Paying for health care… what an odd society.

    1. Wukchumni

      Despite having insurance, i’m about a grandido out of pocket for cataract surgery this week, and you just know more mystery bills will be showing up in the mail, thats the way we roll here.

      1. JBird4049

        Ah, the mystery bills that just randomly arrive even when, being covered by MediCal aka California’s Medicaid. Sometimes months later. They sometimes, they insist instead that I was supposed to pay. Even when it is covered by the system and nothing was to be charged to me.

        Illegal, but I’m sure it went on my FICO. At least, it is better than when I had the very good, not quite gold, company plan. Instead of “take it up with MediCal/Medicare you crooks” I had to deal with it myself.

  16. Tankster

    There a few doctors who are have not been rolled up by groups and employees, who can’t take cash. I have been a cash payer for many years and was a ghost on the MIB.com system (go there and look yourself up. It aggregates your health care info) and then it affects your insurability, credit everything, but I digress. I trained up to waddle the Chicago Marathon 14 years ago and saw an orthopedist and wanted an MRI. Offered to pay Medicare plus 25%, and they treated me like I was from Mars. I had someone from “billing” meet with me and said “Oh we need permission from your insurance company, &tc.” I said how many people do you have (a group practice) devoted to hassling with government, insurance companies, getting your submissions cut and paid 90 days+ after service?” She rolled her eyes. I finally got an off the lot cash (check) price and got it done. What a mess. I’ll be 65 in 5 months so who cares then?

  17. Wukchumni

    My mom is a Great Depression era kid, and as a result she learned to save everything, who knows when it’ll come in handy?

    Some years ago she gave me her checkbook register from mid 1961 to mid 1962, and there are checks for $6 & $7 and one whopper for $14 (must’ve been brain surgery?) written out to Dr. Evers our family physician.

    $88 was the total tariff for a family of 5 on its way to 6.

    My coming out party was $190…

    I asked her if we had health insurance, and she said aside from those in the Kaiser plan, NOBODY had health insurance, everybody paid cash for services rendered.

    1. flora

      My mom is a Great Depression era kid, and as a result she learned to save everything, who knows when it’ll come in handy?

      I like your mom’s attitude. / :)

  18. Sam

    I just recently came across a new issue: sale of patient medical info. I made an appointment with a medical office (after providing insurance info of course) then was asked to complete forms before coming in. The twist was that to complete the forms I had to enroll in a privately sponsored “patient portal” app. As part of the enrollment process I had to agree to their privacy policy which of course permitted them to share all my info with various “affiliates”, “partners” and “service providers” without an opt-out option. When I asked the office for an alternative method for completing the forms I was told that I could not be a patient unless I signed up for the patient portal. They wouldn’t explain why but I assume the practice or their PE owner receives some sort of per capita kickback from the app owners for patient info harvesting.

  19. Mary

    My God, that’s frustrating.
    Thank you for fighting the Good Fight.

    I have learned that avoiding websites, medical portals or any kind of automation in favor of getting a paper statement and or bill in your U.S. Postal mail gives you more leverage and puts the brakes on their desire to digitize your personality and eliminate your rights. “Go paperless”- “Visit our website”-“Save a stamp”-“Go Green!” are all ways for them to save money and you to lose your rights and proof of services if you have to threaten them, go to court, or just deal with someone on the phone.

    Also, always get a hard copy of lab results and a disk of any X-rays or scans, before you walk out of the place where the tests are done. When signing the newly worded “responsibility to pay” statement, write above your signature, “Bill will only be paid after receipt of hard copies of lab results.”

    Having these in hand makes switching doctors much easier and protects you from them losing them or being hacked.

    Once you have been billed for something from a doctor’s office, after the fact, a copay, charge, whatever, you are in a much better position to pay cash, although that ignores the issue of why you couldn’t use cash to begin with.

    Always pay cash to any person who owns their own business. Visa and Mastercard have once again, raised their “swipe” fees.

    It is surprising how general, homeowners and car insurers, at least ours, will allow you to pay bills through your local agent, calling them on the phone and giving them a credit card and you getting points back, versus autopay, or mailing a check to their corporate billing office.

  20. David in Santa Cruz

    Been thinking about this.

    Could be as simple as the provider wanting to make sure that there is a continuing source of payment available should the procedure run into complications — and the patient either runs out of cash or balks at paying for a procedure that didn’t take (which is an elevated risk in orthopedic surgeries).

    Patients can get pretty recalcitrant about having to pay for unsuccessful procedures. I once had to have a gentleman placed on 18 months of electronically-monitored house arrest because he was threatening violence against his doctors over a hip replacement that went bad.

    1. Yves Smith Post author

      First, these are all simple MD visits. None of this is about a hospital, save the first NYC MD who did do a lot of high tech procedures in his office.

      At first I though it might be because he also promoted himself as providing pain management (of no interest to me) and maybe his staff had some fear that cash pay would facilitate some sort of drug fraud. But I can’t work that out at all since any real fraud would either involve providing fake insurance info or the pharmacy.

      Another line of thought is that many insurers might not cover some of his treatments. But that would argue the other way, that he ought to prefer cash patients since there’s no triangular row with the insurer and then the patient over charges. Tons of doctors run their lives to be outside the insurance paradigm, even though insurers will pay for at least some of their services (like endocrinologists who have converted their practices to anti-aging; they make patients cash pay but will often code the bloodwork so that’s covered by insurance, as well as an office visit portion. But up to the patient to seek reimbursement).

      But to your other issue, and hardly anyone realizes this, is that patients have very strong protections on their credit cards. I once went to a clinic in Texas for what they billed as stem cell treatments. It was in fact amniotic fluid, which does not have any live stem cells. I was still willing to try since there’s a long history of MDs in hospitals running to the OB unit and getting amniotic fluid to use as an anti-inflammatory. Also has lots of growth factors.

      A local friend was curious and came with me the date of my treatment. I told the MD, “I’m prepared to entertain that this treatment provides lots of therapeutic benefit, but you can’t call it stem cells because it isn’t. You need to change your marketing on your site.” He insisted it was.

      The treatment was a ton less effective than they indicated. I also dug around in the bowels of their site and found their own blog post that stated that the amniotic fluids weren’t stem cells, along with independent experts saying the same thing.

      I told them I wanted my money back because they’d defrauded me by saying I was getting a stem cell treatment when I wasn’t. I said I would dispute the credit card charge. I got my money back.

      BTW this very same clinic was written up very unfavorably in the New Yorker about a year after my dispute.

  21. juno mas

    Yves, your mobility challenges are difficult to hear. Your experience with the healthcare industry is distressingly familiar to many in the US. No matter how you resolve your orthopedic issues, please talk with a physical therapist about a water-based (pool) therapy to both minimize your current issues, as well as, any post-surgery transition into better movement with less physical impact on your body.

    After many years of youthful and middle age sport activity my hips and ankles just couldn’t take the pounding any longer. A friend (swimming instructor) encouraged me to take her college level swim class (Total Immersion). The change from impact (land-based) activities to low-impact, water-resistant physical activity has been Transformative! Pool exercise (swimming) is aerobic, muscle-strengthening, and easy on the legs. Maintaining regular physical activity in ones senior years is essential for mind and body.

    I’m lucky to live where there is a publicly accessible 50 meter (Olympic) swimming pool. One of my pool compatriots is 90 years old, most are women (the smarter gender?). Learning to swim takes time, but the process is enjoyable and (with ‘learning fins’) not that difficult. The Total Immersion swim technique is about smooth, hydro-dynamic movement, not the intense, six-beat kick seen during an Olympic swim event. It is a lifetime activity.

    Best to you.

  22. Kurt Sperry

    Good luck with the hip replacement Yves, I’ve known quite a few people who’ve undergone that procedure and every one of them has said it was life-changing for the better. Eventually at least.

  23. Louis Fyne

    try doctors with a large number of first-gen immigrants. From the grapevine, they almost always take self-pay even though most/all of them are in the same brand name health networks as any random doc.

    why? have no idea. Can only guess it’s a feature, not a bug. Office managers would rather lose a client than spend the extra time with outlier payment procedures.

  24. Gregory Etchason

    It’s very simple. They can’t justify their charges. So they attempt to avoid any blowback by forcing you to let them bill. When you receive a statement you’re out of the office, services rendered and no longer a potential confrontation. Medicine is truly a most unseemly aspect of capitalism.

  25. clarky90

    Re; “…more asymmetries than most people have, starting with my feet, and troublingly a functional leg length difference as a result of a bad fall that messed up my hip.”

    Hi Yves. Your Sacroiliac Joint (SI Joint) is locked up or lose. Free up (release) or strengthen your SI joints (left and right side) before you have any surgery.

    Sacroiliac Joint (SI Joint) Self Adjustment Technique


    This is just a random video. Search “sacroiliac” on Youtube.

    Find a physio-chiropractor-osteopath-manual therapist that will fix your SI joint dysfunction first. THEN, have them steer you towards a like-minded surgeon for your hip replacement.

    Allopathic medicine is great for a specific task (a hip replacement) when you tell them exactly what you want them to do. They have (almost) no idea why a hip needs to be replaced.

      1. clarky90

        Here is an example of one practitioner; Houston chiropractor, Dr Gregory Johnson. I like how methodical, industrious and mechanical his technique is. No mucking around! (Not for the faint hearted)

        Houstonian Lady With Sacroiliac Joint Pain Adjusted At Advanced Chiropractic Relief


        Finding a practitioner, whom you are comfortable with, AND who also uses a technique that makes sense to you, is a mission, but well worth the time and the effort.

        1. Yves Smith Post author

          Thanks a lot. Problem is finding someone is very very hard. I was given a referral to an osteopath in Delaware who was highly recommended. Despite having a referral, his assistant was difficult and said she’d have him review my MRI report. I followed up a few times at not-pushy intervals. Never would return my calls.

          Similarly, when I had a sub clinical knee problem (I would favor the leg with the unhappy knee after about a minute or two of standing; everything else but standing was OK; it was not all in my head because if you poked around, there were inflamed spots in that knee and not the other knee; I’d also get swollen behind the knee off and on). I spent 15 years seeing everyone from orthopedists to witch doctors. One osteopath damaged me, inflicted a serious eversion sprain on my right ankle when he braced on that calf to adjust my back. And yes, I traveled too in search of help.

          1. clarky90

            Yves, we (your readers) love you! Please, reclaim your good health.

            IMO. learn about sacroiliac joint dysfunction, and then use this knowledge to screen potential therapists. Most are clueless, (FI, therapists who prescribe shoe inserts to “treat” “a shorter leg”…….. or pain killers… ). Generally the more highly qualified and well regarded a doctor is, the more likely they are to be cowards; and working for the Bad Guys (big med).

            I personally like Dr Mercola, and his ilk, who are mavericks.

            Here is a google scholar search of sacroiliac joint dysfunction


  26. Vic

    I switched to a new ophthalmologist in 2019. Went in for my initial appointment — a busy, mid-sized practice. Handed the receptionist my insurance card for vision (MetLife if I recall correctly). Receptionist immediately jumped on the phone to confirm what the plan covered. She got a recording that the MetLife call center was closed due to a hurricane in the area. This brought the entire office to a halt. Two nurses got involved, trying all sorts of different numbers and schemes to get through to MetLife somehow. Ultimately, two nurses and two admin staff were working on this at the same time! After a half hour or so, I realized they were never going to succeed and I offered to pay cash for the visit. I got four bug-eyed stares in return. “You’ll never get reimbursed by your insurance company.” I said I’d take my chances (I hadn’t even thought about reimbursement). I admit I was being lazy by offering to pay when I had insurance, but what dawned on me was that to the staff, medicine was so tightly linked to insurance in their minds that they could literally could not process what I was proposing. They never got to the point of overtly refusing cash payment because they were so shocked by the idea that someone might voluntarily pay out of their own pocket. I finally got my exam (they decided to trust that my insurance was valid), but I walked out of there feeling both confusing and a bit unsettled.

  27. Copeland

    Yves, I’m just curious how you can have a 30 year old policy.

    My policy utterly evaporates at the end of every single year, and a brand new –usually much crappier– policy has to be chosen…every new year.

    1. Yves Smith Post author

      I live in the communist state of New York and this demonstrates you do get something for your taxes. It’s a New York regulated group plan. You probably have an individual plan.

  28. Sean

    How do I get your insurance?

    Also I think to some extent Doctors are not lawyers. They get systems in place and just want to do things the way they always do things. They have staff trained to do things a certain way. Most average people aren’t great at thinking on their feet and just having a rules based this is how we do things works. Makes people more productive. And they also don’t have to worry if your scamming them some how that they can’t figure out. Their old sayings no one gets fired for choosing ibm or hiring Goldman. For the workers if they just do things the same way their not getting fired if things go wrong.

  29. m

    Found a comment could answer your question.

    If your doctor has a contract with medicaid or medi-cal then it is a crime to charge cash or accept cash from you. If your doctor has a contract with an insurance company and he takes cash and does not bill your insurance then your doctor is in breach of that contract.
    That should solve the legality question. Doctors are obligated to not take cash instead of insurance payments, even if you want them too. So it is easier to just say it is illegal.
    On the other hand if you just say “I have no insurance, will you take cash?” many doctors will say yes and even charge you a very low fee. But the second they know you have an insurance that they are contracted with, they will have to come into compliance with their contract. This is a very sticky situation, and why doctors avoid it.


    1. Yves Smith Post author

      No no no no. I am not in a Medicare or Medical plan. The restriction on self pay applies ONLY to Medicare patients and then ONLY for Medicare-covered services.

      I have been seeing all sorts of doctors for decades and self paying. The Medicare/Medical restriction has been operative all this time. Only recently have I run into MD staffers going on tilt when I want to self pay.

      1. m

        There a bunch of comments on this page with the same problem that you are having dating back to 2016
        “I encountered the “illegal to take cash” thing also! In NYC for doctors in the Hospital for Special Surgery. It is the #1 hospital for orthopedics and I’m hearing none of their doctors take medicaid in the private practices. Their billing department also said if someone finds out they took cash, they will incur a “fine”. Is this true?! How can the system allow discrimination against low income people like this? This is so wrong!”

        The healthcare act made so many changes that effect more than just Obamacare, Medicare & Medicaid plans. I will ask around, care coordinators at the hospitals are familiar with billing practices. I pay cash, but have no insurance, have had no issues other than lectures.

        1. Yves Smith Post author

          I have not dealt with the surgical part of HSS. If you have a surgery, you are nuts to cash pay/self pay because 1. hospitals charge hugely higher rates to cash pay customers and 2. If you don’t get your insurer to pre-approve, they will try to reject the claim based on that.

          I am dealing with doctors who have private practices at HSS. I am finding the 3 I have dealt with are solo practitioners. So I assume the doctors are all solo or at most in small group practices. They all set their own rules. The first I saw would not take insurance at all but would give me the form to submit to my insurer, the second needed to be persuaded to let me self pay, and the third flat out refused, so I am not seeing him (wasn’t just the rejection of the self pay, it was also the rudeness and deceptiveness of his assistant, which gave me a bad feeling generally). So they are all over the map.

  30. Lily

    The UK national health service covers everything except opticians, podiatry and dentistry and even they will send you to the NHS for specialist treatment. Additionally you pay for prescriptions but not if you are on benefits. What would that sort of cover cost in the US?

    1. JBird4049

      The United States already pays the most as a percentage of its GDP (18%) than any other country on Earth. If we got rid of the insurers, or at least the large bureaucracy used to extract payments and deny payment of services, probably everything could be covered more cheaply. Or we spend the same amount on some gold-plated wellness and healthcare system.

  31. m

    It appears it is part of contractual agreement between insurance companies & these medical system chains. If they have your info on file they know you have insurance and cannot accept you as a cash patient. You need to lie.
    Many people are going to cash MD & surgical centers since Trump started the price transparency. Some studies showing that paying cash at these facilities cheaper for patients, cost of policy, deductible, etc… vs discount with cash.

    1. Yves Smith Post author

      I know you mean to help but you are not getting it at all.

      First, I am not dealing with “medical system chains”. These are all solo practitioners save one MD in a university system and his office WAS willing to let me self pay but felt they had to check with Cigna because my situation was not familiar to them.

      Second, I have explained repeatedly that these agreements DO NOT apply to me. They apply to members of PPOs and HMOs. I am not in a PPO or HMO. Cigna has confirmed I can self pay, which means that they acknowledge that Cigna PPO/HMO agreements with medical practices do not include me.

    2. Kilgore Trout

      Bottom line is, doctors have a choice to bill your insurance or the patient. Until someone can prove otherwise where it says somewhere in writing, there is no legal or contractual mandate to bill insurance. If I am wrong, please provide the proof.

  32. Kilgore Trout

    In October 2020, a relative needed emergency gall bladder removal surgery. She was enrolled in a healthshare which didn’t cover any of it. Not enrolled in Medicaid. I did all the scheduling. Doctor and hospital had no issue taking cash payment. All dollar amounts were provided upfront. The physician fee went to the doctor’s practice (about $900.) The hospital fee was an estimate and could change depending on how the procedure went, but we were still provided and estimate and paid cash prior to the surgery. No issues and surprisingly smooth. Seems the exact opposite of your experiences. Just adding my experience, not questioning your points.

  33. Sue inSoCal

    Dear Yves, back in the 90s, when PPOs became HMOs, I paid my family doctor cash while I maintained my specialists. I had to do that for 10 years before I moved from the area.

    This insurance/group craziness seems to be fairly new; I don’t know if this’s part of the ACA, physician rebellion at being contractors, or what. I know I feel much more vulnerable on regular Medicare (PPO) now. I hear “We’re not taking Medicare,” etc.

    Another issue that occurred to me is, is it still possible to buy catastrophic coverage or major medical, because in that event, you will per se be required to pay cash for non-hospital events. That would be your situation.

    But I don’t know if “hospitalization” or “major medical” plans exist anymore. One might have to buy a plan now with a monstrous deductible.That might be one reason the billing fools don’t recognize any other form of coverage. (Likewise, one may have plenty of assets to pass on paying for Medicare B. That, too, would be your situation.)

    What your plan is, as you keep trying to explain to medical people, has zero to do with paying doctor’s visits and consultations.

    I’m trying to think of what I’d do and I’m sure you’ve done this, though. All I can come up with is

    “I have major medical insurance (or whatever you want to call it) for hospitalization. I am wealthy and I pay cash for my outpatient treatment. Here’s the letter of confirmation from the insurance company.”

    Or lawyer from Cigna! Or someone legal..

    I am so sorry that you’ve been dealt what I call “the joker health card.” I’m amazed at your ability to keep all the plates in the air, because this stuff is exhausting.

  34. LAS

    I am sorry to hear about your need for a hip operation. I think you are right to be concerned that the apparent difference in leg length is a by-product of asymetric pelvis and back placement. The back muscles may shorten or curve asymetrically as one ages and lead to these kind of effects and someone who tries to level the legs by shortening bone or putting a lift in shoes could make things worse; and I’ve seen that happen in my own family. Compensating for the hip pain may have influenced your back placement and then your leg length. Try doing gentle stretches with your back pressed against a wall to feel for asymetries. Seeing a high quality dance/athletic therapist or sports medicine person could also shed more light. Many doctors aren’t trained to evaluate the systemic body posture and dynamics.

    As for the cash payment thing, the doctors you’ve been seeing have their staff trained like automatons. The doctors’ accountants may have the docs believing (and maybe it is true) that their collection costs are greater, and less favorable where patients are paying directly. Not you so much as other self-payers as a class have impacted their policy.

    Finally, in recovery, you will need sustained good nursing support.

    Suzanne Farrell of the NYC Ballet had a hip replacement around age 40 years or so. She discusses her experience in her bio, “Holding on to the Air”. She names the doctor she used and other particularities of the experience. She was fortunate in her mother being a nurse who helped her navigate the system and the recovery.

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