Cash based specialty carve outs for our DPC patients

(Amy Mechley) #1

In regards to commercially based patients who are using our DPC services: I am arranging a network of specialists who will accept an up front cash based price for their bundled care ( Example set price for colonoscopy or ACL repair). What risk does the specialist or patient run if they chose to pay in cash if their specialist is in network for their insurance ( or even if they are out of network)? I am under the impression that the patient has the right to NOT use their insurance but pay in cash. Are there any examples of commercial insurers contract s that are of concern. What about Medicare/Medicaid? Does the specialist run any risk with their commercial contracts? ( Would run somewhat like a hybrid model I would assume?)
I am getting some shocked specialist faces when I talk with them…:slight_smile: They did not know they were “allowed”!

(Dr Phil Eskew, DO, JD, MBA) #2

The patient has the right under the HITECH act to request that he be charged in cash for privacy purposes. However, when the specialist agrees to this request there is a good chance he has breached the terms of his third party insurance agreements. If were a specialist I would still be fine with this though, since federal law should trump a conflicting provision in a private contract. See #10 on my starting a practice page for more details This same exception could theoretically be tried for Medicare and Medicaid as well, but that federal conflict of laws issue remains unlitigated to my knowledge. Just send the specialists my citations and let them come to their own conclusion.

(Dino William Ramzi) #3

Anecdotally, in the few instances where we have heard of insurance executives coming out publicly and strongly against such direct billing arrangements, they frequently back down, not because of the law but rather because of the public relations optics. Most people immediately understand the greed and manipulation that underlines their attempt to enforce those kinds of contractual obligations.