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The Benefits of Self Pay

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As a cash-based cardiology practice, we strive to evaluate and treat the cardiovascular needs of our patients in a timely manner, and to meet their financial and relational needs as well.

While our cash-based approach won’t be a perfect fit for everyone, we believe that it’s important for people to have the option should they decide they need it.

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Defining 'Cash-Based' and 'Self Pay'

At Trinity Heart and Vascular Group, we use the terms “cash-based” and “self pay” often. We want to explain what those terms mean, and why they’re relevant to modern healthcare.

Medical practices that are “cash-based” offer individuals the opportunity to pay for medical services at a flat rate. From a financial aspect, this means that the practice doesn’t accept payments from any health insurance plans, and instead, receives a flat-fee payment directly from the patient at the time medical services are rendered.

While it’s called a “cash-based” payment system, patients don’t literally have to pay with cash (unless they want to). They can also use credit cards, debit cards, checks, money orders, and sometimes even Apple Pay or Google Pay.

When a patient pays for medical services themselves, they are a “self-pay” patient. This means that the patient isn’t relying on an insurance company to negotiate a price on their behalf (which usually results in the patient receiving multiple bills in the mail). Instead, the cash-based practice lets the patient know upfront what a service will cost, and the patient can pay for that service at the time of their appointment.

Basically, the patient is responsible for paying for their own outpatient testing and procedures the day that they receive those services. The patient pays a flat rate for each service, and doesn’t receive numerous bills for months on end.

Another significant upside, is when patients pay their provider directly (without involving insurance), this can usually save them hundreds, or even thousands of dollars. As a general rule, cash-based practices offer fair-market pricing for their services. This means that they charge prices that correlate with what tests or procedures are actually worth according to the current market.

When using insurance, a patient is billed based on what their insurance company is likely to pay, whether it’s a fair price or not.

While a cash-based practice doesn’t meet the financial needs of every individual, there are multiple situations where it can be helpful. If you’re self-insured, uninsured, part of a cost-sharing program, or have a high-deductible insurance plan, being a self-pay patient can be financially advantageous.

It works in your favor if you go to a provider that offers fair-market pricing for outpatient medical services. Since hospitals usually offer outpatient ‘self-pay’ prices that are over-inflated, it’s beneficial to go to an outpatient private practice that is able to set their own prices.

If you go to a provider that offers “cash” or “self-pay” prices that reflect real-market values, you’ll most likely pay much less for testing and treatment than you would if you received those same services under an insurance claim.

How Self-Pay Prices Can Help Those with High Deductibles

When it comes to outpatient care, one of the downsides of submitting a claim through an insurance plan, is that the insurance company is taking away your right to obtain medical services at a fair-market price. Health insurance plans are generally seen as a way to save money on healthcare costs, but that’s unfortunately not always the case.

When insurance companies enter into contracts with hospital-based medical practices, the prices that hospital systems propose are often overinflated. Why? Reimbursement rates for hospitals have been declining in recent years, so hospitals are trying to bridge the gap by charging way more than they should, in hopes that insurance companies will negotiate a price that’s still overinflated.

The unfortunate part is that their approach usually works. In response to the overinflated proposals, insurance companies negotiate to bring those prices down. However, more often than not, even the ‘negotiated’ prices are higher than what would typically be seen in a competitive, free market.

In regard to out-of-pocket costs, these overinflated ‘negotiated’ prices negatively affect those who have insurance plans with very high deductibles and out-of-pocket maximums.

When you have a large deductible, and are billed for a medical test or procedure through your insurance company, you usually see three things on your bill:

1.) An over-inflated price

2.) How much your insurance company paid 

3.) How much you have to pay

When you see that the insurance company paid less than what the hospital-based medical practice asked for, it leads you to believe that your health insurance is “saving you money.”

It’s misleading because it gives you the impression that you’re paying a fair-market price, when many times, you aren’t. It would be similar to this example:

If you have a standard sedan that uses semi-synthetic oil, paying anywhere from $30 to $60 is reasonable for an oil change (although it might be slightly more or slightly less depending on where you live). 

However, if your local dealership told you that they charge $400 for a standard oil change, but the oil manufacturer stepped in and gave you a coupon for ‘$250 off,’ are you actually getting a good deal? No, because $150 for a standard, semi-synthetic oil change is not currently a free-market price.

In the same way, when you see insurance “discounts” on your EOBs (‘Explanation of Benefits’) for your high-deductible plan, those may or may not be true discounts. Many times, they’re not, which means the amount you’re paying is more than what the service is actually worth. The value or worth of a service is determined by what patients are willing to pay in a competitive, free market.

At Trinity Heart and Vascular Group, we believe that you should have access to medical services at their true market value. We don’t mark up our prices and apply discounts – instead, we give you a fair price from the start.

Why We've Chosen a Cash-Based/Self-Pay Model

At Trinity Heart and Vascular Group, we provide cash-based, fee-for-service cardiovascular medical care, which means that you pay a flat fee for any service that you need. We don’t charge a monthly membership fee, as our practice provides outpatient services on an ‘as-needed’ basis.

We’re able to offer this because we don’t accept payments from any insurance payers, including Medicare (we have an ‘Opted Out’ status). Instead, patients pay for services themselves as a ‘self-pay’ patient. We have chosen this model for several reasons, the most important reason being, we want to have the freedom to help you in the best possible way.

Here are the top four reasons that we run our practice through a self-pay/cash-based model: 

1.) It restores and preserves the provider-patient relationship. Historically, medical care has been about the physician-patient relationship in a covenant of trust. Introducing a third-party payer, such as a health insurance company, creates an unhealthy relational dynamic because it allows the insurance company to make decisions about what types of tests and treatments patients can receive (which shouldn’t be the case).

A cash-based model puts the decision-making back into the hands of those it belongs to — the patient and the medical provider.

2.) It enables our physicians, advanced practice providers, and staff to spend time on what truly matters – delivering the highest quality of medical care. Since we aren’t weighed down by excessive paperwork from insurance companies, we’re able to spend quality time with our patients, which allows us to pursue diagnostic and therapeutic excellence.

3.) It enables us to offer lower prices due to substantially lower overhead. When a medical practice employs staff to verify, submit, and process insurance claims, they have to pass that cost onto their patients in order to keep the business up and running. Since we don’t work with any type of insurance company, we don’t have to employ additional staff to work on claims, which means that we can keep our prices as low as possible.

4.) It allows us to offer fair, transparent, market-based prices, which don’t need to be adjusted based on what a third party is willing to pay. Like buying groceries, gas, or a set of tires, both the patient and medical provider know upfront what the price will be for any given service. In our practice, there isn’t an ambiguous price range based on who is paying. Our flat-fee prices are posted on our website, and are readily available to the public.

How Our Office Accommodates Those Who Have Insurance

Even though our practice doesn’t accept insurance payments, we strive to accommodate everyone’s financial needs. As such, we offer a hybrid approach for those who have a low-deductible or no-deductible insurance plan. This allows you to pay out of pocket for office visits at our practice, while utilizing your insurance at a different facility for any cardiac testing.

If you know that your insurance fully covers cardiac testing, and you prefer to be a patient at our practice, but want to use your insurance for tests, we’re happy to accommodate you. Learn more about how our Hybrid Approach can benefit you if you have a low-deductible or no-deductible plan, or if have a high-deductible plan, but have already met your deductible for the year.

Furthermore, as a courtesy, we provide all patients with a ‘charge sheet.’ This is a receipt that lists ICD-10 codes (diagnosis codes), and also lists the specific services that were rendered (with CPT codes).

If you choose to do so, you may submit your charge sheet to your insurance company for potential reimbursement (paid directly to you), or for application toward your deductible (“out of pocket” expenses) since we are considered “out of network” providers.*

This can be especially helpful if you have a high-deductible plan, and are able to be reimbursed by your insurance company.

If you have Medicare, we invite you to read about our ‘Opt-Out’ status, and how we can accommodate your needs in that environment. 

*Please note that we cannot guarantee that your insurance carrier will reimburse you for any office visits, testing, and/or treatments obtained from Trinity Heart and Vascular Group, nor can we guarantee that they will apply related expenses to your deductible. All patients are strongly encouraged to contact their insurance carrier ahead of time, to verify the terms and conditions regarding services that are rendered by out-of-network providers.

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