upairman

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Nov 21, 2006
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I just finished residency and bought a general dermatology practice out west. I have a well run cosmetic side that obviously takes only cash, but my questions relate to providing medical services. The practice currently has quite a few cash pay medical patients, and they were being charged rates much lower than insurance would normally pay. I recently raised the cash pay rate, since it was likely some of the lowest in the country. I know talking specific numbers is taboo on this forum, but do any other attendings have a specific percentage of medicare fees they charge cash paying patients? I am also finding it difficult to charge for certain procedures (like benign/premalignant destruction), which dramatically increases patients out of pocket costs. Over time many of these patients will leave the practice when they realize I am no longer the cheapest guy in town (with me likely getting some bad yelp reviews in the process), but I want to set up a good system for the future. If you are taking cash pay patients, are you taking a credit card prior to the service to prevent the "I only have 40 dollars on me"? Also what do you do with the patient that has such a large skin cancer on their nose that they require Mohs and a likely paramedian forehead flap, that obviously won't be able to afford needed services (this occurred last week)?

I currently love my practice, and for only owning it for a month am doing great. The cash pay aspect is really the biggest thorn in my side, and is not necessarily needed for future growth. I am also continuing to see several very complicated and disadvantaged patients for free, which I think is an important part of giving back. I have recently had a dentist, lawyer, and a physical therapist (all strangely without insurance) complain about paying more than 50 dollars for my services however, which is very frustrating. Any thoughts?
 

asmallchild

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I just finished residency and bought a general dermatology practice out west. I have a well run cosmetic side that obviously takes only cash, but my questions relate to providing medical services. The practice currently has quite a few cash pay medical patients, and they were being charged rates much lower than insurance would normally pay. I recently raised the cash pay rate, since it was likely some of the lowest in the country. I know talking specific numbers is taboo on this forum, but do any other attendings have a specific percentage of medicare fees they charge cash paying patients? I am also finding it difficult to charge for certain procedures (like benign/premalignant destruction), which dramatically increases patients out of pocket costs. Over time many of these patients will leave the practice when they realize I am no longer the cheapest guy in town (with me likely getting some bad yelp reviews in the process), but I want to set up a good system for the future. If you are taking cash pay patients, are you taking a credit card prior to the service to prevent the "I only have 40 dollars on me"? Also what do you do with the patient that has such a large skin cancer on their nose that they require Mohs and a likely paramedian forehead flap, that obviously won't be able to afford needed services (this occurred last week)?

I currently love my practice, and for only owning it for a month am doing great. The cash pay aspect is really the biggest thorn in my side, and is not necessarily needed for future growth. I am also continuing to see several very complicated and disadvantaged patients for free, which I think is an important part of giving back. I have recently had a dentist, lawyer, and a physical therapist (all strangely without insurance) complain about paying more than 50 dollars for my services however, which is very frustrating. Any thoughts?
My practice has had a similar issue. While most of the physicians in my group were charging Medicare allowable (or even less), the global mandate now is that we bill 150-200% of Medicare but if the pt is willing to pay in full at the time of service, a significant % discount is given (up to 50% I believe). For gen derm patients, I believe they must pay for the office visit before being seen and the front will settle the balance depending on what procedures were performed.

Not sure how the group handles self pay Mohs cases yet however

We do our fair share of "free care" as well and I do admit it's difficult to be seen as a "money grubber". Over time, however, I have had fewer and fewer qualms about charging the full rate particularly for professionals like the ones you've mentioned. Dentists, lawyers (in particular, they bill you for emails and phone calls!), and physical therapists likely wouldn't do ANY work on you for $50. Heck, you can't even bring your car into a mechanic for less than $50. And somehow doctors are supposed to be the only ones taking a haircut on their fees? I guess I really am getting more cynical with age :)
 

MOHS_01

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It's a growing problem... and one that is only compounded by all of the other changes in reimbursement. There is no great answer, unfortunately.
 

Creflo

time to eat
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May 16, 2007
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I am interested in the concept of a cash based practice, charging what you want to charge, but thought you could only do this if the patient either had no insurance or you were not on the patient's insurance plan. Is this true? Seems to me charging less than what the insurance company would pay, while the patient is under the deductible, would be attractive to patients who are under their deductible.
 

MOHS_01

audemus jura nostra defendere
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I am interested in the concept of a cash based practice, charging what you want to charge, but thought you could only do this if the patient either had no insurance or you were not on the patient's insurance plan. Is this true? Seems to me charging less than what the insurance company would pay, while the patient is under the deductible, would be attractive to patients who are under their deductible.
That would be a violation of your contract with the insurance plan assuming that you are a participating provider. The first half of your post/question is true.
 

Creflo

time to eat
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May 16, 2007
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Any thoughts on how many patients are out there with high deductibles, and where this is trending? I wonder if its feasible to establish a cash based practice in something other than family medicine/derm/psychiatry? These are the only ones I've read about. In particular, I am a podiatrist and would like to give it a shot, but noone seems to be doing this.
 

MOHS_01

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There are a lot of patients with high deductible plans; the problem is the majority of these plans have zero out of network benefits. Without OON benefits, any dollar spent does not count toward the deductible - essentially negating any pricing advantage you might be able to offer.

There are no easy outs; the system is hurting both physicians and patients.