When opening their offices, many Nurse Practitioners look for ways to meet the needs of the uninsured and under-insured patient. This can often be a challenge because of several rules and regulations are in place regarding fee schedules particularly with Medicare. For instance it’s my understanding that you cannot bill a patient less than your Medicare allowable.
In the most recent issue of Family Practice Management, Brian R. Forrest, M.D. discusses the business model where he only sees patients for a flat fee. He does not take Medicare nor does he use sign any other insurance contracts. And according to his article, he is able to cover his overhead on four visits per day, hence the title of his article Breaking Even on 4 Visits per Day.
One of the most appealing things about this type of the model, is that you do not have to deal with billing insurance companies. A great deal our time is spent talking with insurance companies about coding, why they rejected a claim, and what we can do to get this claim paid. Between that, all the prior authorizations that we have to obtain for prescriptions or referrals, you almost need to hire one full-time person. It’s a very frustrating and an efficient way to provide health care.
Another Nurse Practitioner in our town recently opened her practice. She is only the second NP to own her own practice in our area (I, being the first). Her model initially was to be cash only in to see people on a walk-in basis. With the number of uninsured people in our community she felt it would be a great service. In addition she is fluent in Spanish and had hoped to reach that community as well. However what she found was that people still didn’t want to pay, even though her fee schedule is far less than an individual would have to pay elsewhere.
While I am not giving up on the model that Dr. Forrest proposes, I will still need to do much research to see how I could make it work in my community.
Read the article, think about it, and look at your own community. This is something that could work for you in your community? Could you do this by joining forces with another nurse practitioner and sharing resources?
I think it needs to be an individual practice decision. I have looked at the area where I am starting, and 80% of the people love to use debit cards, and have insurance. I learned from working in the same town for the Retail company TakeCare, that patients really do not carry cash around, and if they do have insurance, they will walk away and drive 30 miles, so they save 30.00. I do not know that I would do that personally. But do to this factor, despite the incredible work and time it takes, I feel I need to get credentialed with as many insurance companies as possible. We do have one massage therapist in the building that is credentialed with many, and the other one takes only cash/checks. They both do ok, but that is massage, which patients have different expectations. Also, massage is not always reimbursed by insurance and most patients do not hold that expectation. It is a great article by Brian Forrest that you provided though . I have also found that Qwest labs is willing to provide a “provider” lab price, so if patients pay up front for their labs, to the provider, it will cost them less, than if they just pay for the provider visit, and then get a bill from the lab. You can contract with Qwest, and list your most common panels, and get a price sheet for your patients. Then if you draw their labs right there at the office, they can pay you up front. But if they have insurance, I would just send the copy of the insurance with the labs for the courier, and just bill them for the visit. Carla
Another option is to offer a prompt pay discount at time of service and/or for a limited period post visit. The Medicare guidelines are specific about not charging anyone any different than Medicare. So if you charge someone $50 for a 99212 visit, that charge must be consistent across the board to Medicare, Medicaid, insured and cash paying folks. But it is permissible to offer those paying at time of service a percentage discount. Say 20%.
Many “fee schedules” are based on Medicare. I have heard that 150% of Medicare allowable is the going rate. That may increase the revenue generated from insurances but it hurts the self-pay patient and may price you out of the market for the self-pay patient or the patient who has a huge deductible.
We must be mindful of remaining viable in our respective markets. I try to charge similar rates to those offices around me.
An old DO had a cash only practice a few miles from where I am located. He charged $25 per visit, kept no records, had no staff, billed no insurances. You walked in, looked around and when everyone else who was there when you walked in was gone, it’s your turn. His patients loved him. No one would have ever considered suing him. Life was straight forward. He retired in January 2006; his absence may be one of the contributing factors to my success. His business model showed me that in the right environment and circumstances a cash practice is viable.
I am entirely too aware of the litigious nature of people today to try anything without record keeping, though!
In a situation where a FNP works for a company and bills insurance, but also has a private business in holistic care that is cash based and does not accept insurance – do they need seperate malpractice insurance policies?
In most cases, you do not need two separate policies, but this is a question for your liability carrier.
I work as a hospitalist NP, but want to open a private cash only practice. But the kicker would be not having a place where people can come see me but rather go to them. Having the office in my home be my office for charting or etc… Problem is not sure if that is something I can do? Would anyone know if thats okay to do or not?
Yes, you can do this – basically it’s a “house” call type of practice. Your business office can be where you want it.
I work for a family practice group and bill insurances through them for the day job. I’m interested in opening a cash based business on my days off and weekends. Will there be an issue with Medicare? (Opt-out- it’s all too confusing!)
It will be an issue only if you accept cash payments from Medicare recipients for covered services. Opting out is not that confusing if you realize that if you opt-out, it’s global – including for any jobs you have.
Thanks for the information! Can the nurse practitioner, starting a brand new practice, bill a flat fee for office visits while waiting for credentialing to be complete? Basically, can an NP start seeing patients at the practice and charge each patient a flat fee for services, and then switch to billing an insurer when they are credentialed?
Yes, you can. Give your patients a superbill so they can attempt to get reimbursed. Just remember, you cannot back bill insurance companies, except with Medicare (but only after you have started the credentialing process with them).
I am an RN strongly considering entrepreneurship but would like to do strictly cash pay. I’m not sure where to start however I see this business heading in the concierge, home health type business (to include but not limited to lab draws and drop offs, health coaching, med management, etc). I know the end, just not the means and I’m not even sure where to start. Is this something feasible in Florida? Any direction is greatly appreciated.
Any entrepreneurial endeavor starts with a plan. You have the vision (though it needs tweaking), just reverse engineer it to get it where you want. Make sure you are keeping SOP in mind as well as any other state rules for nursing and business. Good luck
I am a new PMHNP looking at opening my own practice. I will work for another practice 2 days a week. They will credential me for them. My private practice will be cash only at first. Can I get credentialed for my private practice while also credentialed for another practice that I do not own?
Yes, you can credential yourself under your business, while being credentialed under another company. This is no different than if you were working two jobs and each clinic was credentialing you at the same time. It comes down to the business NPI and EIN.
I'm enjoying the questions and responses here. Its very informative!
As a PMHNP with a private cash practice, can patients submit bills for psychotherapy and/or med management visits to their insurance companies for reimbursement?
Would patients have a problem with prescription coverage for psych meds such as SSRIs if prescribed by a non-participating, cash-only provider?
1. Assuming you are not credentialed, out of network, and have no contracts…Yes, patients can submit their bills. Their reimbursement will not be great (usually), but they should get something.
2. The only potential issue would be having insurance pay for it. That may vary with each plan.
Hello!
I'm in need of seeing a NP in my area of Berlin, NJ.
Because my former husband cut me off on my insurance, and didn't pay what was due to me via our Divorce Decree? So, I'm left needing a pay cash upon time of service or debit card (whichever is required), in order to get the medicine I'm out of, but it is important I get! I'm an individual, in need of a Dr, so I'm a potential patient Please inform me where I may go to get medical help, simply for a refill. I recently relocated back to NJ. Thank you kindly!
I don’t know what kind of an office you need, but I would do a Google search for something like “primary care offices in Berlin, NJ”. Best wishes to you.
If I want to start my own telehealth business to avoid overhead , what address would I use for credentialling if I do not have an office location?
You can use your home address, but then you run the risk of all that information being public. You can also get a virtual business office address where you can receive all your business email.
I am really amazed by this site. I have learnt a lot just by reading the comments. I am a Adult-Gerontology NP based in Texas. I am also licensed in Florida and waiting for my NP license in Maryland. plan on starting a cash based practice, I recently purchased a course and I am halfway ready. The thing is looking for a niche to focus on, where people won't have any problem with paying cash, and also retaining those patients. Ideas will be appreciated. I am looking at weightloss, men's health, concierge. With weightloss, I heard that insurance now pays for it, and I am not sure if it will benefit me at the long run if insurance can pay for something. Please advise. Thanks
Hello Theresa,
Part of finding that niche is part of the beginning process of doing your due diligence. You want to take each of these areas you are looking at and do some research:
– What is the problem or desire you have a solution for?
– Is there a market for the services, how large is it, and who exactly will the patients be?
– Are people (insurance) willing to pay for it, and more importantly, will they pay your asking price (or if insurance, what is the allowed amount they will pay you for the service).
Then you want to know as much as you can know right now, what your cost are going to be, and will be you able to bring in enough patients to cover your cost.
In terms of retaining patients, you can do your best, but there will always be attrition in any practice. Your marketing never stops.