Purpose
To outline the correct process when a patient requests to transition to private pay (self-pay) status instead of using insurance.

This process protects:

• Patient privacy expectations

• The practice from payer audit exposure

• Compliance with the No Surprises Act (Good Faith Estimate requirements)

• Consistent financial communication

Overview

Patients may request self-pay status for a variety of reasons, most commonly privacy. When this occurs, we can honor the request — but the waiver must be signed before any change is made in the system.

This protects both the patient and the practice.

Workflow

Step 1 – Provide Private Pay Agreement

When a patient requests self-pay:

• Send the current Waiver of Insurance Billing (Private Pay Agreement) via portal.

• Inform the patient that the agreement must be signed before changes can be made.

• Do not alter billing status until the signed form is received.

Step 2 – Review Signed Form

Verify the following:

• Patient name printed

• Signature present

• Date completed

• Relationship to patient (if minor)

Step 3 – Good Faith Estimate (Federal Requirement)

Under the No Surprises Act, self-pay patients are entitled to a Good Faith Estimate (GFE).

• A Good Faith Estimate must be provided upon request.

• For scheduled services, a GFE should be provided if the patient is uninsured or electing self-pay.

• The estimate should include expected charges for services reasonably anticipated.

• If actual charges exceed the estimate by $400 or more, the patient has dispute rights under federal law

Step 4 – Update Account

• Change category to: Self-Pay

• Change payment source to: Self-Pay

• Remove active insurance/set to inactive

• Document on insurance note waiver of ins billing

• Document in Quick Notes this change

Billing Rules Under Self-Pay

• Payment is due in full at time of service.

• We do not submit claims to insurance while the agreement is active.

• A superbill is automatically generated for the patient’s records.

• We do not retroactively convert visits to insurance billing.

• Rates may differ from contracted insurance rates.

If a patient independently submits documentation to insurance, reimbursement is determined solely by their insurance plan. Staff should not guarantee reimbursement.

What Not To Do

• Do not switch billing status without a signed agreement.

• Do not promise insurance reimbursement.

• Do not rebill prior visits to insurance after processed as self-pay.

• Do not discourage patients from asking questions about privacy or coverage.

When Patients Want to Switch Back to Insurance

Patients must notify us in writing.

Before switching:

• Confirm eligibility and active coverage

• Confirm services provided under self-pay will not be rebilled to insurance

• Document change clearly in chart