Can primary care doctors refuse to take insurance?

Yes. Doctors aren't required to accept health insurance plans or to accept the rates insurance companies decide to pay. The Affordable Care Act improved health insurance access, but it didn't resolve the issue of rising costs and lower reimbursements offered by some payers.

Many choose not to work with particular insurers or government payers like Medicare and Medicaid that offer lower reimbursements to doctors. Instead, they may move to cash-only medical practices.

"It's becoming more common lately. Insurance companies are denying claims and making it harder for doctors to accept patients in their plans by lowering reimbursements. Consequently, lots of doctors are dropping plans," says Lily Talakoub, MD, FAAD, a board-certified dermatologist in McLean, Virginia.

Why do some doctors not take insurance?

Some doctors don't take insurance for several reasons, including the difficulty of working with insurance companies and the rates set by those companies.

Physicians negotiate the price of treatment with health insurers. The health insurance company sets the rates that it will pay the doctor. Insurance companies may also include quality metrics that doctors must meet for full reimbursement. Insurers set rates, but that doesn't mean the physician must agree to these rates.

Lower reimbursements from insurers have prompted some doctors to stop accepting plans and coverage from those insurers.

But decreased compensation isn't the only reason many healthcare practices are cutting ties with insurance carriers.

There is a lot of paperwork associated with insurance companies. Each patient with insurance comes with an extensive amount of paperwork. Plus, many insurance companies try to deny coverage at every turn. Ultimately, this leads to hiring more staff to manage the paperwork or tackling the paperwork nightmare on their own.

When health insurers lower reimbursement rates, Talakoub says, insurance companies force doctors to see more patients, which isn’t good for patient care.

"The doctor's office then becomes a factory and patients suffer," Talakoub says. "Also, insurers commonly don't approve medications or tests that doctors recommend, making the administrative burden horrendous for doctors to deal with as they try to appeal their decisions as advocates for their patients."

Direct primary care vs. cash-only medical practices

With all of the difficulties of dealing with insurance companies, more doctors have stopped taking insurance.

Of course, someone has to pay the tab. When physicians decide to stop taking insurance, patients have to foot the bill.

Doctors who request cash payments effectively cut out the extensive paperwork requirements of the insurance company, which means less of an administrative burden on the doctor and their staff.

Some practices charge patients a flat or reduced/sliding scale fee for office visits and treatment. Others offer "concierge medicine," in which patients pay a monthly, quarterly, or yearly fee or retainer for a predetermined number of services or visits.

Direct primary care is one type of program in which the patient and health care providers set up a financial arrangement. Direct primary care removes health insurance from the equation. So, the provider doesn't file health insurance claims but instead works directly with the patient through a monthly or membership fee.

The benefit of direct primary care is that you won’t have to deal with health insurance companies. However, you may also have to pay more for care since a plan no longer helps you pay for coverage.

What happens if a hospital does not take your insurance?

If a doctor or a hospital doesn’t accept your health insurance, there are a few steps you can take.

Contact your insurance company

Reach out to your insurance company. You can explain the situation and ask for an appeal. Sometimes, the insurance company will agree to negotiate with your doctor.

But if the issue is that the doctor doesn’t want to accept funds from an insurance company, you’ll have no choice but to pay cash or find a different doctor.

Check your network coverage

"Chances are, the services you require are available in your network from an alternative physician or service provider in your area who accepts your insurance," says Nick Schrader, an insurance agent with Houston-based Texas General Insurance. "If so, try to see that doctor instead."

Ask your doctor’s office if it will submit your insurance claim

"If your physician is outside of your insurance network coverage, ask if they will submit an out-of-network claim as a courtesy to you," Talakoub says. "If not, ask if they will provide documentation that can help you submit a claim yourself with the necessary paperwork and documentation attached."

Request a reduced fee or flexible repayment terms

If a doctor doesn’t accept insurance, they may be willing to negotiate payment terms with the patient. You might score a discount for paying upfront or find flexible financing options if you ask the front desk.

Ask if the doctor offers concierge medicine options

Your healthcare provider may agree to provide treatment and services for an annual, monthly, or regular prepaid fee.

Consider switching insurance plans

Your doctor may accept a new plan or policy with a different carrier. Confirm with the provider what health insurance plans the practice accepts.

Inquire about payment assistance options

"Check to see if the practice or hospital has financial assistance options that can reduce or eliminate your bill, depending on your financial need, and determine whether you are eligible to acquire that," Schrader says. "If you qualify, you'll probably have to pay something out of your pocket, but very minimal."

Go to an urgent care clinic instead

Walk-in clinics that provide non-emergency services may charge a lot less than private practices, hospitals, or medical centers.

What to do when your doctor doesn't take Medicare

Most doctors accept Medicare. Only 1% of all non-pediatric physicians formally opted-out of the Medicare program in 2020, according to the Kaiser Family Foundation.

Medicare doesn't pay at the same rate as private insurers. Doctors who accept it are often only reimbursed around 80% of what private health insurance pays. This is one of the reasons why some physicians don't accept Medicare.

But if you learn that your healthcare provider doesn't take Medicare, you have options. Perhaps you could negotiate a discounted or sliding scale fee or see if the practice offers flexible financing options. As a last resort, be prepared to find another doctor who accepts Medicare; ask your physician for a referral to a fellow practitioner who does.

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Preferred-provider Organization (PPOs)

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The Affordable Care Act created insurance exchanges that allow people to compare plans. The health law also requires insurers to accept everyone and not charge them exorbitant rates. People who make below 400% of the federal poverty level qualify for subsidies to help pay for an ACA plan.
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Silver is the second most popular plan in the ACA exchanges, with 35% of people with a Silver plan. Silver has lower premiums than any plan except for Bronze. However, it has lower out-of-pocket costs than Bronze. Silver plans pick up 70% of the costs, while members pay 30% The average single coverage in a Silver plan is $481 monthly and $1,179 for a family plan.

Bronze is the most popular type of plan in the ACA exchanges, with 41% of members with a Bronze plan. These plans have the lowest premiums, but also the highest out-of-pocket costs in the exchanges. Bronze plans pick up 60% of the costs, while members pay 40%. The average single coverage monthly cost in a Bronze plan is $440 and $1,080 for a family plan.

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Platinum plans have the highest premiums but the lowest out-of-pocket costs. So, you pay more for the coverage initially but less than other plans when you need health care services. Platinum plans pick up 90% of the costs, while members pay 10%, Not many health insurers offer Platinum plans. Only 2% of members in ACA plans have a Platinum plan, so you may have trouble finding one. The average monthly premiums for single coverage in a Platinum plan is $706 and the average family coverage costs $1,460.

Gold plans have lower premiums than Platinum, but higher premiums than Silver and Bronze. Gold also has lower out-of-pocket costs than Silver and Bronze, but higher than Platinum. Gold plans pick up 80% of the costs, while members pay 20%. The average monthly premium for a single Gold plan is $596. Family coverage averages $1,426 per month.

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Health insurance FAQs

What if my doctor doesn’t accept Medicaid?

If your doctor doesn’t accept Medicaid, ask if they accept other insurance options. If paying for a different insurance policy or covering out-of-pocket medical costs is not possible, then it’s time to switch providers. Check out your state’s Medicaid website to see which doctors in your area take Medicaid.

What is it called when a doctor doesn’t take insurance?

When a doctor doesn’t take insurance, they are considered a cash-only doctor. Other ways to describe these doctors include direct pay or direct primary care doctors.

Sources