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HEALTH Insurance
HEALTH INSURANCE INSIGHTS

Some doctors don't accept health insurance. Here's what you need to know about your options when doctors don't accept your insurance. 

why doctors stop accepting insurance

You head to your doctor's office for medical care. But upon arriving to your office visit, you learn that the doctor doesn't accept your health insurance plan. The out-of-pocket cost you'd have to pay without health insurance is expensive. What should you do?

The truth is, many physicians don't accept certain forms of health insurance. In fact, plenty of doctors today choose to forego working with health insurance carriers altogether and require cash payments from patients. For instance, consider that only 71% of doctors accepted Medicaid in 2019, according to the Medicaid and CHIP Payment and Access Commission.

It's important to understand why many physicians are rejecting health insurance plans and requiring cash payments instead, as well as your options as a patient under the circumstances, including direct care from primary care doctors and other providers.

KEY TAKEAWAYS
  • Many doctors don't take some types of health insurance and some even don't accept any insurance. 
  • Doctors may stop taking insurance if they believe the health insurance company isn't offering enough compensation.
  • If a doctor stops taking your health insurance, you have a few avenues, including asking if the doctor will take a reduced fee or provide flexible payment terms. 

Can primary care doctors refuse to take insurance?

Yes, doctors aren't required to accept health insurance plans or the rates that insurance companies decide to pay doctors. The Affordable Care Act looked to improve 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 doctors decide to go insurance-free

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 to get full reimbursement. Insurers set rates, but that doesn't mean that the physician has to 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 health care practices are cutting ties with insurance carriers.

"Doctors simply don't like dealing with insurance companies," says Ann Martin, director of operations for CreditDonkey in Pasadena, California. "Not only does it involve a lot of paperwork and forms, but insurance companies are notorious for finding every possible way to deny coverage. Doctors and hospitals are forced to hire more staff to manage these issues or fight the insurance companies themselves. Either way, it's a huge logistical time suck, all in the name of getting paid."

When health insurrers lower reimbursement rates, Talakoub says insurers force doctors to see more patients. That’s not good for patient care, she says. 

"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."

Rise of direct primary care and cash-free medical practices

Doctors who don't take insurance is on the rise. It's little wonder that some doctors have decided to increasingly or exclusively accept money only for treatment and services.

Of course, someone has to pay the tab. When physicians decide to stop taking insurance, that means patients have to foot the bill -- at least those patients who choose to do so.

"Asking for cash payments from patients cuts out the insurance middleman, making it easier for doctor's offices," Martin adds.

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 and/or visits.

Direct primary care is one type of program in which the patient and health care providers sets up a finacial 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. That may include a monthly fee and/or a membership fee.

The benefit of direct primary care is that you may like not dealing with health insurance companies. However, you may also have to pay more for care since a plan is no longer helping you pay for coverage.

What to do when your doctor rejects your health insurance?

If your health care practitioner doesn’t accept your health insurance, there are steps you can consider taking:

Contact your insurance company

"Call them and state your case. Sometimes they'll honor your appeal. If the issue is the doctor wanting cash or not wanting to deal with the insurance company, however, you may need to either pay up or move on," suggests Martin.

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," recommends 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

"Physicians who don't accept insurance are sometimes willing to negotiate with patients by reducing out-of-pocket costs or by offering flexible financing," notes Martin.

Learn if the doctor offers concierge medicine options

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

Consider switching insurance coverage

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

Inquire about charity options

"Check to see if the practice or hospital has charity 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 a private practice, hospital or medical center.

Pay what the doctor asks

If you've exhausted all other options but value this practitioner's services and expertise, it may be worth it to stay on as a patient and pay your bill in full.

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 among the reasons why some physicians don't accept Medicare.

But if you learn that your health care provider doesn't take Medicare, find out about your options. Perhaps you could negotiate a discounted or sliding scale fee. Possibly 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.