What is a Direct Pay Practice?
The concept is actually quite simple, but with the complex medical reimbursement system in our country, it might seem rather strange to some people.
Basically, here is how it works:
- You, the patient, have a responsibility to me to pay for my surgery service (Direct Pay), and I in turn have a responsibility to you to provide that service, for an agreed-upon price. Payment is received prior to service.
- Your insurance provider has a responsibility to provide you reimbursement for your medical expenses, to the extent allowed in your insurance policy, which you have de facto agreed to.
- As I am not contracted with your insurance provider, there is no relationship or responsibility between me and your insurance provider.
You are probably used to the scenario where the doctor’s office handles the insurance paperwork, and you walk out after perhaps only paying a co-pay for the visit, and pay any co-pay for surgery sometime in the future after insurance pays their portion (assuming they actually pay, rather than deny the payment for a million different possible reasons). Depending on your insurance provider and the complexity of the services rendered, this process can be fairly smooth, or it can be one of the most maddening ordeals of your lifetime. For PPO insurance, this should be fairly smooth, as I would be considered an out-of-network provider.
After years of battling insurance companies and government payers, I chose to avoid being a part of these maddening ordeals, and became a Direct Pay Practice. When necessary, I do provide patients the basics of what they need to seek reimbursement from their insurance provider. These items may include: A letter requesting surgical pre-authorization, diagnosis and procedure codes (ICD-10, CPT codes), chart notes, etc. As always, you own your medical record and a copy can be made for you. (We may charge a small copying fee if more than a few pages are requested.)
Charges for other services, such as hospital fees, surgicenter fees, pathology fees, and pharmaceutical costs, may or may not be covered by your insurance carrier. Any questions regarding these should be directed to your insurance carrier, preferably before surgery. If surgery is performed at Surgical Arts Surgery Center, you will be given an invoice which outlines the facility fee portion of your out-of-pocket, up-front costs. If insurance reimburses a facility fee beyond this amount, please be aware that this will not be credited against your surgeon fee. Please contact our office for clarification if you have any questions about this.