Cash pay price and fee schedule

Cash pay patients

One question everyone has is how much to charge for cash pay patients, as well as refractions. Some folks who just opened are desperate to bring patients in the door so will give a big discount to cash pay patients. My advice: very bad move.

If a patient has insurance us you’re almost always contractually obligated to bill the insurance and not see them as cash pay. If you make your cash rate lower than the insured allowed amounts, then the patient doesn’t have the incentive to use their insurance. This might be a better deal for the patient before they meet their deductible. But then they might ask you to bill their insurance after they meet the deductible, and it might be past the filing limit. Yes, I know a patient could pretend to be uninsured and never show you their card.

Next, you don’t want patients picking you based on being the lowest price in town. That attracts a certain type of personality- the one you don’t want to build your practice on. You want to build your practice based on patients who appreciate and respect your knowledge and treatment plans.

Your cash pay rates need to be higher than your highest insurance allowed amount. For most ophthalmologists, Medicare is the highest payer. Everyone needs to make a table of their allowed amounts for the most commonly billed codes. The Medicare and your state’s Medicaid plan can be found online. Google your state, or your MAC should have links. For commercials, if this wasn’t given to you with your contract, contact your provider rep or provider services to get this information. You must know this information to be able to collect the correct amount for deductibles and coinsurance at the time of service.

So my cash rate is 110-120% of Medicare. Otherwise the insurance company could argue that you need to give them the same discount as cash pay patients- and therefore would lower their allowed amounts for you. Yes, I realize there’s time and effort to verifying patient insurance, collecting at time of service, sending In and posting claims, which isn’t necessary for cash pay patients.

I don’t make up the rules here; just trying to keep everyone out of trouble. Perhaps new laws about the transparency of health care costs will change this. This article agrees with my viewpoint, along with the fact that you may be breaking state law with cash pay rates lower than insured allowed amounts.

For refractions and premium lenses, make phone calls to practices in your area and pretend to be a patient. Again, you don’t want to be the cheapest guy in town, but it may not make sense to be 25% over what everyone else is charging. I charge $40 for a refraction.

Fee schedule

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