Author Topic: Self-Pay or Out of Network?  (Read 556 times)


  • Newbie
  • *
  • Posts: 1
Self-Pay or Out of Network?
« on: August 03, 2017, 07:46:45 AM »
Hi guys,

I'm a physical therapist looking to start my own independent out-patient homecare business.  I'm new to the forum and have gained insight on a lot of the questions that I've been having.  I have been a PT for 12 years as an employee, but I am very new to the insurance billing game.  I have a lot of clinical experience but very little insurance reimbursement experience.

I currently became an in-network provider for Cigna and I have a patient with a high deductible Cigna insurance plan that she has not met yet.  Would it benefit me as a provider to have the patient opt-out of her insurance plan?  Is that even allowed as an in-network provider?  She is willing to pay cash for her treatments due to her high deductible.  She does have a Health Spending Account that she wants to use for her treatments.  If she opt's out, should I notify her insurance at all?  She wants to opt out, but I don't understand how that would benefit her because she would be paying out of her own pocket for the treatments but not have any of that money applied to her deductible.  Am I wrong in assuming that?

Pardon my limited knowledge on insurance reimbursement.  I have clinical expertise in my field but have very limited knowledge on how to get reimbursed for my treatments.  I have been an employee for as long as I've been a therapist and have been kept in the dark regarding insurance reimbursement (sometimes I think on purpose by my employer).  Its time that I go out on my own...  Thanks ahead of time for any advice.

Jeff S, DPT


  • Global Moderator
  • Hero Member
  • *****
  • Posts: 4931
    • Solutions Medical Billing
Re: Self-Pay or Out of Network?
« Reply #1 on: August 03, 2017, 10:01:23 AM »
If she opts to not submit to her insurance then her Health Spending Account won't pay.  The claims have to go thru her insurance to access that. 

I believe the patient can opt to not use their insurance, but you need to have it in writing in their chart.  Being a participating provider you signed a contract with CIGNA so you want to make sure you are covered if they ever ask why claims weren't submitted. 

You definitely cannot charge her a lower rate but bill the insurance to help her meet her deductible.  (You didn't ask but in case others reading aren't clear on that.)

If she has a Health Spending Account why doesn't she want to submit so that the visits will be covered by that?
Sign Up for our FREE Medical Billing Newsletter
Get a 10% discount on Medical Billing Products by using Coupon Code: 10OFF


  • Hero Member
  • *****
  • Posts: 4341
    • One Stop Resources & Networking for Medical Billers
Re: Self-Pay or Out of Network?
« Reply #2 on: August 06, 2017, 05:54:42 AM »
There are many types of Health savings accounts that have no requirements and don't bother to coordinate benefits at all, so it is possible to use that rather than the insurance. My own HSA only requires me to submit receipts and I can use it for anything health related, even over the counter meds. 

But, none the less your thinking is correct, she has no benefit to NOT filing her insurance. YES patients may opt to not have claims filed even if the provider is participating but as you mentioned, she won't have any of her money applied to deductible.

Another thing to consider is that if she's going to be receiving a cash pay discount, there is a good chance she may end up submitting claims herself to have the actual CHARGE applied to her careful with that and if you do offer her a discount, make sure that the itemized billing receipt/charge slip SHOWS the actual charge, the discount and her payment in case she should submit it. If you only provide her a bill showing the discount amount as the charge and she submits it, it would be considered a false claim on your end as well as hers!

Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers