How much control do you have over your healthcare purchases? The story usually goes something like this: your doctor writes an order for a procedure, you take the order to the next provider who takes your insurance card and sends you off to get your procedure done. Sometime after you’ve had your procedure, you get an explanation of benefits telling you what your insurance paid. This is usually the first time you’ll see a price. If you’re lucky, your insurance will have covered the total. If not, expect more bills to come.
Sound familiar? Healthcare is the only industry where it’s commonplace for the consumer to hand over so much control over what they spend to third parties. Fortunately, since everyone is a patient at some point, the law is on our side. It protects two of the most important rights involved in our medical care: privacy and choice.
Your Right to Protect Your Privacy
You’ve probably heard of HIPAA, even if it’s just in a title of one of the many forms you have to sign at your doctor’s office. HIPAA stands for the Health Insurance Portability and Accountability Act of 1996, and one of its most important features is the protection of your health information. You have the right to access your health information and to know who else has seen it.
HIPAA got a major update in 2009 with the American Recovery and Reinvestment Act, which expanded the power of patients to limit who can see their protected health information (PHI). You can request restrictions on what entities can see your PHI, especially if that entity is not related to your care. If you’re insured, this provision means that if your health insurer isn’t paying for your care, you can ask that information about your service not be released to them. It also means that you have the freedom to choose whether you want your insurance to pay for your procedure or not.
Your Right to Pick How You Pay
It’s easy to assume that if you have insurance, you have to use it. But there may be cases where it’s more affordable to pay out of pocket for your service – like through MDsave.com or your facility’s self-pay prices. In these cases, as long as you are paying in full and out of pocket for your procedure, you can request that health information regarding that service is not sent to your insurer.
If you have insurance but you don’t want your PHI sent to them, be sure to tell your provider upfront, before receiving your service, that you would like to restrict sharing of information about this procedure. Let them know that you will fully pay for the procedure yourself.
The right to restrict the sharing of your PHI with your insurance company for services paid in full and out of pocket is detailed in 45 C.F.R. sec. 164.522(a)(1)(vi) of the Electronic Code of Federal Regulations . (You can read it at the end of this blog, or in full here).
Your Right to Take Back Control
As a patient, you have the right to choose how you want to pay for your care. Sometimes your insurance will have the best price, but not always:
“With my high deductible plan, my procedure would’ve been five times more expensive.” – Jeannine from Dresher, PA
“I liked knowing the cost upfront. I actually paid less than my insurance would have.” – Marcia from Tomball, TX
Sometimes, paying out of pocket can save you money. You, as an informed healthcare consumer, have the right to leave your insurance company out of the transaction. Take charge of how you get your healthcare.
(a)(1) Standard: Right of an individual to request restriction of uses and disclosures. (i) A covered entity must permit an individual to request that the covered entity restrict:
(A) Uses or disclosures of protected health information about the individual to carry out treatment, payment, or health care operations; and
(B) Disclosures permitted under §164.510(b).
(ii) Except as provided in paragraph (a)(1)(vi) of this section, a covered entity is not required to agree to a restriction.
(iii) A covered entity that agrees to a restriction under paragraph (a)(1)(i) of this section may not use or disclose protected health information in violation of such restriction, except that, if the individual who requested the restriction is in need of emergency treatment and the restricted protected health information is needed to provide the emergency treatment, the covered entity may use the restricted protected health information, or may disclose such information to a health care provider, to provide such treatment to the individual.
(iv) If restricted protected health information is disclosed to a health care provider for emergency treatment under paragraph (a)(1)(iii) of this section, the covered entity must request that such health care provider not further use or disclose the information.
(v) A restriction agreed to by a covered entity under paragraph (a) of this section, is not effective under this subpart to prevent uses or disclosures permitted or required under §164.502(a)(2)(ii), §164.510(a) or §164.512.
(vi) A covered entity must agree to the request of an individual to restrict disclosure of protected health information about the individual to a health plan if:
(A) The disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and
(B) The protected health information pertains solely to a health care item or service for which the individual, or person other than the health plan on behalf of the individual, has paid the covered entity in full.