In 2018, I partnered with NVISION Eye Centers to buy a very successful existing cash-pay cataract and refractive practice in California’s San Gabriel Valley. The cash-pay model is becoming an increasingly attractive option due to the challenges we face with insurance and declining reimbursements. Many of us are tired of dealing with the mounting paperwork, need for prior authorizations and, most importantly, what we feel is an overall environment of insurance companies undermining our medical decisions. All of this takes us away from our priority of caring for our patients.

With a cash-pay practice, there is no need for staff to contend with any of the insurance requirements such as coding and billing. My team is 100% dedicated to serving patients and helping them achieve their best vision; the focus is on education and counseling. Cutting out insurance dramatically simplifies the practice flow.

Being a cash-pay practice, I have the privilege of operating out of an in-office surgery suite instead of an insurance-based ASC. As a result, patients feel comfortable since their surgery is taking place in a familiar environment, and we offer flexibility in scheduling the procedure. We can also price procedures at a competitive rate for those patients who otherwise would not be able to afford the high facility costs associated with an ASC.

Here, I provide best practices from our cash-pay cataract and refractive practice and explain the various considerations that go into operating your own cash-only model.

DISCUSSING CARE OPTIONS

The nature of a cash-pay business allows us to provide care without the worry about presenting patients with covered and noncovered options — and having patients make decisions based on cost. Instead, we present them with whatever technology we believe they would be most suited for.

For example, when it comes to cataract surgery, we don’t convolute the conversation with different pay models for insurance and out-of-pocket “add-ons.” Instead, we explain to patients that, although basic cataract surgery with a monofocal lens is covered by insurance in other practices, our goal is to provide them with the best chance of being glasses-free. So, by default, we utilize premium lenses and femtosecond laser technology for all patients who are candidates. Comparisons of different cost packages don’t even enter the conversation. We’re simply offering the best technology available.

In particular, the discussion in a traditional practice model regarding basic monofocal lenses vs premium lenses is bound to address a significant difference in out-of-pocket costs for the patient. In an all-cash practice, the difference in cost between these lenses ends up being negligible for the patient. Again, not having money come into the conversation allows us to focus the conversation on patient desires and clinical outcomes.

When approached in this way, we have found that patients are willing to pay out of pocket for premium service regardless of what lens they choose. Rather than discussions of covered vs noncovered, my staff and I can focus on providing excellent care from beginning to end.

PACKAGING CARE

Another factor that simplifies the conversation with cash pay is it allows us to package together our offerings for cataract patients. Rather than itemizing each and presenting patients with a confusing menu of options and prices that are covered or non-covered, technologies such as femtosecond laser and premium lenses are in our base offering. These packages also include care options that are not tied to insurance reimbursement, such as oral sedation and same-day bilateral cataract surgery as well as preoperative exams including OCT of the macula and nerve head, endothelial specular microscopy and wavefront aberrometry, which are not typically covered by insurance preoperatively and so are not always performed as part of the cataract work-up. However, I believe these are essential tests for evaluating the premium IOL candidate.

Rather than having the patient obtain drops that may or may not be covered at their pharmacy, we also include any postoperative antibiotics and anti-inflammatory medications as part of their surgical kit at no additional cost. This not only offers patient convenience, but it also helps ensure that the patient is has the correct medications in their hands and reduces the chance of non-compliance.

For patients with dry eye disease, we also include a preoperative “dry-eye kit” containing eyelid scrubs, preservative-free artificial tears, ointments and samples of prescription medications to maximize optimization of the patient’s ocular surface and reduce the barriers to obtaining essential medications that will influence their final surgical outcomes. For patients who require more intensive dry eye treatment postoperatively, we will sometimes include in-office treatments for meibomian gland dysfunction at zero or significantly reduced cost.

These treatments are not usually not covered by insurance and would otherwise be a substantial out-of-pocket cost for the patient. The profit-margin with a cash-pay model allows us to build in these “cushions” to provide our patients with greater flexibility and premium service regardless of their ability to pay.

IMPORTANCE OF STAFF

To be a successful cash-pay practice, you have to deliver excellent care and service, which means you have to spend the time and resources to hire and educate staff who can help you to do so.

Our cash-pay practice has a boutique feel, which lends itself to high levels of customer service. So, when we hire staff, we prioritize those who have excellent communication skills, a friendly disposition and an innate talent for conflict resolution.

In addition, our staff is properly trained on all things ophthalmology. For example, patient counselors play a crucial role in our cash-pay practice. Mine have close to 20 years of experience working in an eye clinic, which is important since they function like the face of the clinic. In fact, they each take ownership of every new patient and become their point-of-contact and advocate from beginning to end. They even share their cell phone numbers with patients and are in constant communication with them. As a result, our patients’ phone calls or messages do not go unanswered. Our patient counselors come to know the patients very well and treat them like family in many cases.

During the preoperative process, patient counselors see the patients after the surgeon’s visit with them and continue the conversations about our technology offerings. It’s their job not only to discuss the financial and logistical aspects of surgery, but to also reiterate the value of our services and set proper expectations related to the technologies so patients understand what they are paying for.

These responsibilities require patient counselors to have a thorough understanding of the IOL technologies we use as well as the preoperative and postoperative care, so we prioritize staff education and training. My patient counselors started off as ophthalmic technicians, so they have the baseline knowledge necessary to guide the patient through their surgical journey from beginning to end.

To educate staff in a cataract and refractive practice, there are several in-person and online resources available. We utilize Alchemy Vision, which offers video-based education that is ideal for onboarding new staff. Also, when a new technology is introduced in our practice, we have a team dinner or training session. Many of these are set up with the manufacturers as they understand the importance of proper staff education.

MEETING A HIGH STANDARD OF CARE

As a cash-pay practice, we set an extremely high standard for ourselves. Because patients have high expectations when paying out of pocket, they will be unhappy if these are not met. This dictates that we must hit the refractive target and consistently deliver premium results. Our enhancement rate is extremely low, and our patient education and counseling are very thorough. We spend time ensuring patients know exactly what they are getting, and we hold their hand through the whole procedure.

If there is a problem, patients don’t want to pay extra for a follow-up procedure or to treat that problem. One example is postoperative dry eye disease that requires additional medications or a device-based intervention. Nothing is 100%, so you have to build into your model how you are going to handle these situations.

Along with explaining this to the patients verbally, we build such contingencies and acknowledgment into the paperwork that they sign. An example could be wording such as “I understand that I have preexisting dry eye disease. Because it’s a long-term condition with no cure that requires chronic management, I understand that I will need to continue treatment after surgery and that financial responsibility is my own.”

Another example is for patients who have a history of refractive surgery that might lead to unpredictable outcomes. We always tell them there is a higher chance they may need a touchup or enhancement and there is a small fee that is strictly to cover our service fee for operating the laser.

It is our policy for patients to acknowledge that if their target refraction is not achieved and they require an enhancement or touch up to correct any residual refractive error, they are responsible for the fee. This is also included in the preoperative paperwork that patients sign.

As mentioned previously, the communication between our team members and patients is critical. If a patient has any issue or concern, we see them the same day — no exceptions. Surgeons who are not interested in a customer-service minded way of practicing medicine may not work well in a cash-pay setting.

MARKETING

Another difference between traditional and cash-pay practices is how we attract patients and get our referrals. With no insurance network to funnel patients in a traditional way, we market ourselves exclusively direct to the consumer, though we do receive a small number of referrals from community ophthalmologists and optometrists.

Our marketing is similar to our in-office discussions: we advertise better vision and freedom from eyeglasses, not specific procedures. This simple message ultimately targets LASIK/PRK, implantable collamer lens (ICL), cataract and refractive lens exchange (RLE) patients who want to be glasses-free and understand that typically these are elective services not covered by insurance.

Beyond advertisements, word of mouth is crucial in this setting. Most of our patients are friends of friends, neighbors and family members who have heard about the excellent care we provide. Our patients know us through our reputation as longstanding and trusted members of the community and are confident we will treat them like family. We offer incentives for those referring friends or family for consultations in the form of gift cards (Visa or Amazon, for example).

OFFICE-BASED SURGERY

With our cash-pay model, we have an office-based surgery suite, which is a driving factor for why many of our patients decide to go with us rather than through an insurance-based system. One benefit is that it gives patients flexibility. I operate almost every single day including Saturdays — we work around their schedule, not the other way around. In addition, patients have familiarity with your office already, so it’s a setting that can put patients at ease if they are worried about having a procedure in an unfamiliar environment.

Operating in-office is not exclusive to a cash-pay practice. You can still adopt an office-based surgery suite with a mixed cash-pay/insurance model by performing both insurance-covered and uncovered procedures as more and more private insurances are now reimbursing for in-office surgery.

DIVERSE PATIENT BASE

I think people may have the misconception that only the most affluent patients will pay cash for premium technologies and elective vision procedures. We have found this not to be the case at all. We see a diverse patient population including working-class folks who prioritize their glasses-free vision due to their jobs or lifestyle. Many of them have saved to have surgery because their vision is their livelihood. They may not have insurance or be woefully underinsured and would otherwise not have access to presbyopia-correcting technology that can help them become glasses-free. We must not prejudge who can afford these types of procedures.

CONCLUSION

For those looking to grow a cash-pay segment of their practice, you can begin by taking a step-wise approach. Start by offering more out-of-pocket services, such as RLE, LASIK, PRK, ICL, dry eye treatments and aesthetics services such as Botox and fillers. You can also increase your premium IOL conversion rate. Perhaps one day a week, you can focus solely on cash-pay patients in order to optimize practice operations for that patient base.

I have found practicing in a cash-based model to be an incredibly satisfying experience. Most of us never realized how much of our time as physicians would be spent on billing and coding, pre-authorizations and administrative work. These tasks get in the way of what it really means to practice medicine and do what is best for our patients. In my cash-pay practice, I can spend my time on what I enjoy: caring for patients and performing surgery. OM

Dagny Zhu, MD, is a cornea, cataract and refractive surgeon currently practicing as medical director and partner at NVISION Eye Centers in Rowland Heights, Calif. She is active on social media with more than 50,000 followers on Instagram. Follow her @DZEyeMD on Instagram as well as on Twitter, Facebook, TikTok and LinkedIn.