Presented by Founder & CEO, Dr. Miles Bodzin

Question: Can a patient opt-out of insurance even if you're an in-network provider?

Short answer - YES. (Except Medicare patients) Thanks to HIPAA/HITECH regulations you have the ability to have a patient opt-out of filing their health insurance. The only caveat is they must pay you in full.

It’s not uncommon to see patients with deductibles in the $3,000-$10,000+ these days. If you are a network provider, you know that your provider agreements require you to file claims with the insurance carrier.

We want to be a good corporate citizen and encourage you to honor those agreements. But, we also have an obligation to let patients know what their payment options are.

Thanks to HIPAA/HITECH regulations you have the ability to have a patient opt-out of filing their health insurance. The only caveat is they must pay you in full.

Here’s Why This Works

In February 2009, former President Obama signed into law the American Recovery and Reinvestment Act (ARRA). Part of the ARRA brought about major changes in the Health Insurance Portability and Accountability Act (HIPAA). Certain provisions of the ARRA have impacted the insurance world and how you practice. The HIPAA compliance enforcement got its teeth to deliver a bite with the Health Information Technology for Economic and Clinical Health (HITECH) Act. If you have not updated your HIPAA compliance manual to reflect these changes, you may now face significant fines.

Previously, fines up to $25,000 maximum could be levied. Now the fines are tiered and could be as much as $1.5 million in fines for just a single HIPAA violation.

Your Notice of Privacy Practices (NPP), commonly known as a Privacy Policy, must reflect the required changes and associated policies in your office. Part of the NPP must address the patient's rights pertaining to their protected health information (PHI). The patient has the right to obtain a copy and review their PHI. If the patient disagrees with the PHI, they have a right to request that the practice amend the PHI.

The patient also has the right to request that the practice restrict the use and/or disclosure of PHI for treatment, payment and health care operations. On Feb. 18, 2010, the HITECH Act regulated that a health care provider is required to honor a patient's request to restrict disclosure of PHI to a health plan for purposes other than carrying out treatment (specifically, payment or health care operations) if the patient pays the health care provider out of pocket in full. [Section 13405 of Subtitle D of the HITECH Act (42 USC 17935)]. This means that if a patient does not wish to use their health insurance or med-pay, they can request that the insurance is not billed. A PPO cannot require that you file a claim for the patient, although if you do not, then you may be required to have a written attestation that the patient requested the restriction. Medicare is the exception for covered services.

Full act here:

  • REQUESTED RESTRICTIONS ON CERTAIN DISCLOSURES OF HEALTH INFORMATION.-In the case that an individual requests under paragraph (a)(1)(i)(A) of section 164.522 of title 45, Code of Federal Regulations, that a covered entity restrict the disclosure of the protected health information of the individual, notwithstanding paragraph (a)(1)(ii) of such section, the covered entity must comply with the requested restriction if-
    • Except as otherwise required by law, the disclosure is to a health plan for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment); and
    • The protected health information pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full.

Thanks to HIPAA/HITECH regulations you now have the ability to have a patient opt-out of filing their health insurance. The only caveat is they must pay you in full.

If a patient elects to opt-out of their insurance you should have them sign an election to self-pay form (located below). Also below is a revocation of self-pay in the event the patient meets their deductible and would like you to begin using their insurance. The conversation with the patient goes like this:

Staff: Mrs. Jones, we verified your insurance benefits and you have a $5000 deductible. In most cases similar to yours, it’s not uncommon for care to run $90 to $100 per visit, and that is what you would be expected to pay until your deductible is met. Honestly, most patients hardly ever reach a deductible that high in our office and find that it’s more affordable for them NOT to file their insurance if they have one of those discount medical cards like ChiroHealthUSA, do you have one of those?


Staff: Mrs. Jones, most patients with a high deductible like this will never meet it in our office and they find care is more affordable if they are part of a discount medical plan, are you a member of one of those?

Patient: No

Staff: Not a problem, that is why we are part of ChiroHealthUSA®, that’s a network you can join in our office today for $49.00 for the year, and it covers you AND your family. Under this plan, your visits would be $45.00 per visit instead of $90-100 per visit. Would you like to hear more about that?

Patient: Sure

Staff: If you choose to do this you will be opting out of us filing your health insurance for you and we would provide you with a receipt for your visit. Once you join the network, there is a simple form called the "Election to Self-Pay" that outlines this process.



Disclaimer: You cannot do this for Medicare patients. We do NOT encourage doctors to force or require patients to opt-out of filing their insurance as a condition of treatment, but they should be aware of current regulations that permit opting out as long as the guidelines are followed. It may be helpful to have the insurance network's position on this in writing for your compliance manual.

We do recommend that you read and review your provider agreements with your payers. We do NOT advise doctors that they may have patients opt-out of insurance in every case and always have, and will, continue to defer to your third-party payer-provider agreements.

You should follow the advice of the insurance network regarding their patients for covered services. Insurance network customers, your patients, are certainly eligible to join ChiroHealthUSA® and receive any network discounts available for their NON-covered services just as any other member of the public.

Finally, you should ask the insurance network their policy regarding patients CHOOSING to opt-out filing their insurance based on privacy issues or any other reason THEY choose, provided they pay the provider in full for the services. Recent federal regulations have made it clear that patients have this option, even taking precedence over provider agreements.

This information is courtesy of ChiroHealthUSA®

Related Articles: