Alright mommas tell me if you’ve ever heard of this. Is it insurance fraud to pay out of pocket for a medical procedure instead of going through with your insurance? I was recently told it was. I’ve just never heard of this before.
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I’m not sure how it’s fraud if you choose to not use your own insurance.
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No not if u pay for it
I literally just paid out of pocket for my yearly OBGYN. It’s not insurance fraud. You can pay for the procedure however you wish. Wether it be cash, card, or insurance.
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Did you hear this from someone within your state or outside of it? Because I’m pretty sure some states you can’t pay cash unless it’s a copay. Idk about insurance fraud though.
Nope. People pay out of pocket for many specialists not covered by insurance. It’d be insurance fraud in the sense that you are frauding the insurance company itself, such as false claims, or using their resources to commit crime.
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No people often do it with different types of insurance to avoid it going up.
No because it’s paid for
No it’s not. Sometimes it’s cheaper, for eg if you have an excess to pay and the cost maybe cheaper, or if you want to avoid paying a higher premium if your no claims aren’t protected
Where’s the fraudulent act? Fraud includes deceitfulness.
What they may be thinking is that it would be medicare fraud. If on government insurance you have to use it, you can’t even pay for a prescription out of pocket. Private insurance you use if you want too
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Question do you mean insurance or like medical insurance thru the state. In california if someone has medical we cannot let them legally pay out of pocket. But for reg insurance they can.
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It is in our country, we pay if it is not part of our coverage. Sometimes, we do the reimbursing procedure. When you have a procedure done its part of your insurance coverage but due to red tape or long processing if documents you pay it for the meantime. Its accepted and still within legal bounds here.
No because you can opt to not use insurance at any time you want… most people would just rather use it because it can be cheaper (sometimes it’s not). They know they can get insurance to pay more so they’ll up the cost of certain things sometimes. Whoever told you this is trying to BS you. Go elsewhere
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It’s not fraud but if you have insurance and decide to run it they might not take the cash. They want the insurance. This is the problem I have run into
I want to say no, but at the same time I feel like saying that you don’t have insurance to get a cheaper price and then submitting that as a claim to you insurance company could be considered fraudulent.
No way I do this all the time with prescriptions and dental care… Cash prices are drastically less than through insurance in some cases
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No, a lot of people pay out of pocket for procedures not covered by insurance, if insurance would take too long, if the provider you want to use doesn’t take the insurance, etc. your insurance is happy to not pay.
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I believe as long as it’s not Medicaid, then no it’s not fraud
No its absolutely not
Not true. I am saving up to pay out of pocket for a 5 year birth control because my main insurance won’t pay anything of it. Which is funny because if I had just my secondary insurance it would be covered in full.
I have insurance but sometimes it’s cheaper not to go with the insurance at the time as the access $$$ is more then the medical
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Insurances laws are state specific. I would suggest writing your states insurance commissioner.
I don’t see how using your own money instead of making an insurance claim qualifies as fraud, but who knows. Maybe your states insurance commissioner has some underlying regulation that all Healthcare services(since the ACA made having Healthcare insurance a legal requirement) must be filed through insurance and the person at your place just used fraud to describe it.
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Let me ask you, why are we all so worried about other people? Does this really concern you?
They are saying it’s a scam because to some people paying money Is a scam
That alone is a scam in itself. So they have something to argue the insurance companies over
If you have medicaid/medi-cal or whatever your state funded insurance is called, the provider can’t make you cash pay something that would be covered under your insurance.
Makes no sense, how is fraud if you are not using it?
Some procedures are not covered, take too long to be authorized, or the copayment is to high that is actually cheaper to pay it yourself
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Actually no it shouldn’t but I’d def find out for sure
No, now if the office takes your insurance, technically by law, they have to bill your insurance first UNLESS they know it is a non-covered procedure and they have you sign a form acknowledging that you understand this.
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It’s not fraud. Just because you have health insurance doesn’t mean you are required to use it.
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Some medical offices choose not to file thru insurance. They ask you to pay out of pocket and then you can make a claim on your insurance. That way if your insurance refuses to pay it, they aren’t stuck with your bill. This is due to insurance companies essentially selling us to the highest bidder. Insurance is the biggest scam this country has ever seen. Every medical establishment has the right to choose what insurance companies they’ll accept or not with the exception of Medicare
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People defraud insurance companies all the time. I don’t know how anyone dares to do that. Fraud comes in many forms that will eventually bite you in the butt. I know someone who sold a house that wasn’t his to sell. He left to someone else.
I worked, for a long time, on both sides of health insurance.
Might be fraud, might not be. It depends on the situation. Is the service that you’re having covered by your insurance? If so, it’s fraud, and it needs to be reported to the insurance. If not, then it’s your responsibility to pay for it. Does the provider participate with your insurance? If so, it’s fraud and needs to be reported to the insurance. If not, insurance won’t pay for it and it’s your responsibility.
If you have an in network co-insurance then you have a portion due to the provider. If you have out of network benefits (which are typically much lower than in network benefits) then you’ll still have a portion due to the provider.
If you have insurance that covers everything and the provider participates with the insurance and they’re still charging you, then yes, it’s fraud.
I would suggest calling your insurance company. They can tell you if the provider is in network or out of network, they can tell you if the service is covered and what, if anything, is your responsibility.
Without us knowing what your insurance coverage is, who the provider is and what services were done, there’s no way for any of us to tell you definitively that yes it’s fraud or no it’s not.
Not to mention, there are some providers that don’t participate with insurance at all, and you’ll be required to pay out of pocket for services and then submit the claim to your insurance company on your own.
There really isn’t enough information in the question.
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If a practice isn’t in network with your insurance and you don’t have out of network benefits, then you can pay cash.
If you have Medicaid and the practice doesn’t accept, you can pay cash.
There are certain procedures that insurances just don’t cover and in this case, you’d pay cash. IE Platelet Rich plasma injections.
Some cases the provider may not accept your insurance but your insurance may still pay if you submit your own billing but pay the provider cash.
There are entirely way to many scenarios but to answer your question in basic form - no. Insurance fraud is when your billed for services never rendered
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No actually you’re not bound by law to use your insurance for a medical procedure. If it ends up being cheaper that way and normally it is, you’re allowed to do that legally
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I’ve been told that in Wisconsin it is
Need more details. If the doctor is not in your network you may have to pay out of pocket and self bill. It’s not fraud. You also have co pays
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You can choose not to use your insurance at any time 
That very statement is ridiculous. Your saving the insurance from paying! I’m sure they are happy about that!
Why would you put out of pocket instead of going thru insurance? Just curious
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The cost of some medical test is cheaper if you pay cash (out of pocket) instead of using your insurance, for instance my husband had a Cat scan done and they told him it would cost 100.00 dollars if he paid cash but his copay would be 250.00 if he used his insurance. Hospitals jack up the cost on insurance companies, sometimes it’s worth it to not file on your insurance.
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Why pay for insurance and not use it?
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No, it is not fraud. They would rather you pay out of pocket then them cover anything.
If u have insurance and it’s covered why would u pay for it
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A lot of people don’t understand how most private insurance is a scam lol. There’s a deductible YOU have to pay… usually between 2-6k. So anything you submit to insurance needs to be paid back up to that amount before your insurance actually pays for it… then it’s only about 80% they pay for after that.
Most places will also be cheaper by around 20% if you pay out of pocket too. They give you a big discount for doing so
It could be if you have medicaid- not regular health insurance through an employer etc. A medical provider who treats you knowing they are not in network with your medicaid provider that allows you to pay for it yourself could be consider insurance fraud on their part depending on what state you live in (unless it is a procedure your medicaid did not cover in which case you could pay out of pocket). The medical provider would need to direct you to a provider who does accept your medicaid health insurance and follows those specfic guidelines with coding, policies etc instead of allowing you to pay for a typically covered service out of pocket.
If a medical provider is contracted with your commercial insurance company (in network) it is insurance fraud on the providers part to treat you as self pay or private pay. As a previous commenter said also, if a provider knows you have any type of Medicaid based plan and allows you to pay for a procedure out of pocket vs running through insurance, also fraud on their end.
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Uhm no lol. But I’d be using insurance unless it’s not covered.
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No not at all. If you don’t want to use your coverage, it only saves them money. It would be insurance fraud if you made a claim for which you never received treatment
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No, it isn’t fraud to choose to pay out of pocket for a procedure. People do it all the time. It’s called the “cash price” and is frequently much lower than the insurance billed price. It can be used for procedures that aren’t covered by insurance or if you are using a practitioner who isn’t “in- network” for your insurance to save money.
Sometimes it’s actually cheaper to pay out of Pocket for Certain things , Believe it or not.
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No its not medical fraud sometimes insurance don’t cover procedures and you have to pay out of pocket
No it’s absolutely not!
No my son has Medicaid and paid for eye exam and glasses .
If i got my life saving insulin through insurance it would cost me $1,250 for a 30 day supply. Instead I have to go online and get a coupon from the manufacturer to only pay $99. Ins can be a total waste and rip off. I hate it.
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How are you frauding them by not using them?
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Cut off whoever told you that, you don’t need any more of their advice.
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Just make sure they don’t also charge your insurance company. Keep an eye on your explanation of benefits. Other than that you’re good to go!
You pay if insurance doesn’t cover it. That’s not insurance fraud
Is the medical insurance, state insurance? Like the medical card, or Medicare? If so, then yes. Per contracts with the Drs and the state they are legally not allowed to let you pay out of pocket for services. They consider that insurance fraud on the drs part.
For example-at 25 yrs old I got pregnant. Went to the Dr and discussed everything. This was my 2nd pregnancy…1st was twins resulting in a C-section. I mentioned wanting to do a vbac, dr agreed as I was very very low risk for complications, and overall an excellent candidate for this!
I was on my dads health insurance plan. They added a stipulation in his insurance saying they were no longing covering pregnancies for dependents (aka me) and only covering spouses on the policy. So I had no option but to get a medical card.
So after the first appointment we discovered the insurance problem. Upon getting medical card I was told that I couldn’t do a vbac as medical card doesn’t cover the “sitting fee” (with vbac once you dilate to a 4 dr is required to remain at the hospital until baby is born-this is the fee he is paid for sitting and waiting) my parents offered to pay the sitting fee out of pocket and then bill the rest to the medical card. The drs office let me know that they are not allowed to charge me for services that aren’t covered as the state considers it insurance fraud.
Hope that all makes sense!
Also, I did get a vbac. I waited until i was far enough into labor that they would have to deliver. I wasn’t going to be forced into an unnecessary surgery over insurance!
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Absolutely not. They are confused lol. Some people have really high deductibles and it is cheaper to pay out of pocket rather than their deductible and copays.
I’m sure that would make an insurance company really mad!
If the procedure is covered by your insurance why wouldn’t you have them bill your insurance? Did you request to pay OOP? Why? There isn’t enough information provided.
Lol your Insurance will thank you.
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you can always pay out of pocket and then submit for reimbursement, altho you might not get as much back because the insurance company negotiates a different price than cash payers.
No. It’s fraud if they charge insurance and you for the full amount of procedure or charge for procedures that weren’t done
If ur insurance doesn’t cover something u need done then it’s not fraud just means u have to pay out of pocket Not all insurance covers 100% of stuff or even some of stuff
It’s not fraud but just inquire about HSAs that way the cash you do save to use on out of pocket payments is tax free and if you want you can transfer that cash to an IRA and still not be taxed…Insurance is fraud at its core …you need two insurances now a days and still go into nasty debt trying to pay off med bills.lol
I had an OB office tell me this as well. Called my insurance company and they told me it was in fact fraud.
No, but keep records of what the charge is and what you paid. I was told I needed to pay my medical procedure up front also, but then they tried to charge me more afterwards. I refused to pay the extra as I paid in full the amount they told me. I’m disputing the remainder
Lmao wait what? How would it be fraud?
Definitely is not fraud though
They paid out of pocket so tell me exactly how it’s insurance fraud 
I don’t know about medical but for my car once the windshield cracked and it was cheaper for me to just fix it then go though insurance so I assume it’s the same for medical?
A lot of things aren’t covered by insurance 
. If you pay out of pocket that isn’t fraud.