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.