Private Pay

Dr. Rivas is also one of the few doctors in the Chattanooga area to adopt a “Private Pay” practice. By minimizing the influence of insurance, health care can be provided more efficiently and most economically. For those who have insurance, they will be provided with billing and claims forms before leaving the office. This can then be submitted back to insurance for reimbursement or for credit towards deductibles.




What is a “Private Practice”?

A “Private Pay” practice may also be known as a “cash pay” or “self-pay” practice. It is similar to “normal” medical practices in most respects. The main difference is at the end of the office visit. Prior to leaving the office, payment for the office visit will be made by the patient directly to the office without involvement from a health insurance company. This aspect will be similar to any non-medical business where payments are made to the business prior to leaving. Payments can be made by check, credit card, flex-spending or a health savings card.

If I don’t have insurance, isn’t it expensive to see a doctor?

That is a complicated issue, but it doesn’t have to be. Much of the problem arises because most medical offices take health insurance. When a physician agrees to participate in any insurance plan, a physician basically agrees to accept whatever payment amounts the insurance companies have predetermined. These payment amounts are generally less than what physicians charge for their services. As a result, physicians generally overcharge to compensate for the fact that most insurance companies pay less than what is actually billed. This artificially inflates the cost of healthcare, making it more expensive.

How is a “Private Pay” practice more cost effective?

By not dealing directly with insurance companies, medical fees don’t have to be artificially increased. As a result, the bill for medical services represents the actual amount that is to be paid, which is generally less than when dealing with insurance. In addition, the overhead and expenses in a private pay office are greatly reduced by not dealing directly with insurance companies. This means that a private pay office spends less money on the extra employees that would normally deal with insurance paperwork. Consequently, a private pay office saves money and those savings can be passed on to patients in the form of lower overall medical charges.

Do I need a referral to go to “Private Pay” practice?

No. Because insurance is not involved, referrals from a primary care or specialist physician are not needed. Anyone can schedule an appointment at any time.

The exception are those patients who have insurance and would like to be reimbursed or apply their expenses towards their deductible. For those with health insurance, a referral by a PCP may be necessary in order to see a specialist. Keep in mind that “private pay” or “self-pay” offices are generally considered as “out of network” for most insurance plans.

Can I go to a “Private Pay” office if I have insurance?

Yes. It is important to note that “Private Pay” practices are considered “out of network” by insurance companies. Some insurance plans do require a referral from the PCP or a prior authorization before seeing an “out of network specialist”. Unfortunately, there are some insurance plans that do not cover any “out of network” expenses.

As long as a patient is willing to submit some basic paperwork to their insurance company, patients should either get reimbursed or apply those expenses towards their “out of network” deductibles. When a patient calls to make an appointment, we will get their health insurance information and call the insurance company for the patient to determine what paperwork or authorization is required. This is to make the filing process easier for the patient. Before leaving the office, all billing information, with the service and diagnosis codes, as well as a standard medical claims form will be provided. This paperwork will help to simplify the filing process.

It is important to note that all visits to CSB will be considered as “out of network”, so patients will need to verify what “out of network” services are covered by their insurance plan. Unfortunately, some insurance plans offer no “out of network” benefits, meaning those patients will not get reimbursed or be able to apply those expenses towards their deductibles. In addition, one should also keep in mind that “out of network” deductibles are typically higher than “in network” deductibles.

If I change insurance or hospital networks, do I need to change doctors?

Not in a “private pay” practice. Many insurance companies and hospitals offer financial incentives to stay “in network” and often make it cost prohibitive to go “out of network”. With modern healthcare, medical practices who take insurance may be “in” or “out” of network from one year to the next, making it difficult for patients to stay with one doctor. A “private pay” physician will be considered as “out of network” regardless of what insurance someone has. This allows a patient to stay with the same doctor, regardless of changes to insurance “networks”.

How is a “Private Pay” practice more efficient?

By reducing the role of health insurance companies in medical decisions.  In healthcare today, insurance companies will very often refuse to pay for something if the appropriate “authorization” was not received in advance.  As a result, doctors basically have to get “permission” from the insurance companies to do just about everything.

For example, if a physician wants to provide a particular treatment to a patient, typically that treatment can’t be given on the day of the visit because the appropriate “authorization” from insurance first has to be obtained.  This typically takes time and means the patient will likely have to come back for a second visit after “authorization” has been received.  As a result, the patient will have to take more time out of their schedule and pay another copay.  All this delays healthcare.

In a “private pay” office, the patient and doctor can decide on a treatment and medical care can be provided at that time, without having to go through insurance first.  This is medicine, as it should be!

How is the quality of care better at a “Private Pay” medical office?

It many ways, the quality of healthcare is better at a “private pay” office than at regular medical offices. Because health insurance companies have reduced payments to physicians over the year, there is a large amount of pressure to see more and more patients each day to make up for these decreases in payments. As a result, providers often have so many patients on their schedule that they now have very little time to actually spend with each patient. Subsequently, patients often feel like their physician may not listen to them or even take the time to actually do an exam on them. These are complaints that are often heard from many patients today. With less time for each patient, health issues may get overlooked and even missed. Overall, this brings down the quality of healthcare.

This is not the case at a “private pay” office. At a “private pay” office, patients will find that physicians will have the time to listen to them and will actually take time to examine them. Patients may be surprised to find that the doctor may actually have time to talk to them when they call and may even greet them when they check in for their appointments. Patients will get the kind of personal healthcare at a “private pay” office that is very rare in medicine today.

What are other benefits of going to a “Private Pay” office?

Another benefit of going to a “private pay office” is knowing that you won’t be getting any bills from the office after the office visit. When a medical office takes insurance, they typically have to wait at least 60 days to find out if the insurance is going to pay, and if so, how much. The medical office is then obligated to bill the patient for whatever amount of the charges that were not covered by the health insurance company. If the insurance claim gets denied and has to be resubmitted, it usually takes an additional 60 days to get a response back from the insurance company. This means that a patient may get a bill from the medical office months after an office visit for whatever amount the insurance did not cover. It can be very frustrating not knowing if you will get a bill for an unknown amount of money in a few months.

At a “private pay” office, one has the benefit of knowing exactly how much they are paying for their medical services. In addition, they can take comfort knowing that when they have paid the bill before leaving the office, that bill is actually paid for. No surprise bills will be sent months after the office visit because the insurance company took their time to decide if and how much of the medical charges they wished to pay for.

Another benefit of going to a “private pay” office is better medical record privacy for patients. Insurance companies have the right to view medical records from any medical office that accepts their health insurance. At a “private pay” office, health insurance companies do not have the right to access medical records without consent by the patient. There may be situations where this may be desired by and beneficial to a patient.

How can a “Private Pay” office help a small business?

There are ways that a “private pay” medical practice may benefit a small business. With the rise in health care premiums, many small businesses are not able to afford to provide health care coverage for their employees. Many small business owners still wish to help their employees should any health issues arise. Because costs are lower than other “traditional” medical offices, small business owners may find that they are able and willing to cover medical costs for their employees. An employee may be evaluated at a “private pay” office and can pay with the business credit card or even a company check. There is very little paperwork to worry about, as opposed to dealing with regular company health insurance or Workers Comp. This can definitely be a benefit to small businesses that wish to do a little more for their employees, without much of the expense or bureaucracy.

How much does it actually cost to see Dr. Rivas at Chattanooga Spine and Body?

Call the office for information on pricing and to schedule an appointment.