The process is simple, a business transaction where buyer and seller agree on price, not a faceless back room third-party intermediary whose pricing methodology is grounded in moral hazard.
This simple process requires legwork by plan members. They become an active part of the transaction, a responsibility they have never had before. And they are rewarded for their efforts when they succeed.
MEDICAL SERVICES CASH PAY PROGRAM ELECTION FORM
STEP 1 – Provider Completes Request – The provider completes this form with the member’s information and the services to be rendered. Patient then submits it to the Health Plan.
STEP 2 – Health Plan Determines Cash Pay Amount – The Health Plan reviews the request and enters the approved Cash Pay Allowed Amount for each service.
STEP 3 – Provider Accepts or Rejects Offer – The provider reviews the Health Plan’s Cash Pay Allowed Amount and either accepts or rejects the offer before services are rendered.
SERVICES TO BE RENDERED
| Date | CPT Code | Description of Service | Provider Cash Price | Health Plan Cash Pay Allowed Amount | Provider Decision |
| $ | $ | ☐ Accept ☐ Reject | |||
| $ | $ | ☐ Accept ☐ Reject | |||
| $ | $ | ☐ Accept ☐ Reject | |||
| $ | $ | ☐ Accept ☐ Reject |
PROVIDER CERTIFICATION
I certify that the information contained on this form is true and accurate. I further certify that the services listed above are medically appropriate for the identified member.
If I accept the Health Plan’s Cash Pay Allowed Amount, I agree to accept that amount as payment in full for the approved services listed on this form. I understand that no additional payment will be sought from the member.
| Provider Signature | ______________________________________________ |
| Printed Name | ______________________________________________ |
| Date | ____ /____ /_______ |
HEALTH PLAN USE ONLY
You don’t need permission from your BUCA administrator or any other third party administrator to do this. And you don’t need stop loss insurance on cash transactions either. Some things in life are so apparent they defy naysayers paralyzed with fear of failure into do nothing inaction producing harmful effects that don’t need to be.
