What a direct-pay provider network is, from the practice side

A direct-pay network is not a payer contract with a different logo. The economics, the administration and the risk all sit differently, and a practice evaluating one should understand the trade rather than the brochure.

The honest version of the pitch has a real concession in it. Any version that does not is leaving something out.

What a practice gives up

You publish a price. That is the substantive concession and it is not a small one, because a published price is visible to every other payer you deal with, to every patient who compares, and to every competitor down the road.

You also agree that the published price is the whole price for the defined service. You cannot add a facility fee afterwards or bill the patient for a remainder, because under this model there is no remainder — and a practice that tries to create one has broken the thing that made the arrangement work.

Finally, you accept that the service has to be defined tightly enough to price. That is administrative work up front, and it is genuinely harder for some specialties than others.

What a practice gets

You are paid at the point of booking rather than thirty to ninety days after submitting a claim, and the amount is the amount. There is no adjustment, no denial, no appeal and no partial payment to chase.

The administrative load attached to that revenue is close to zero. No eligibility verification, no prior authorisation, no claim submission, no resubmission, no statementing, and no collections on a patient balance the patient never agreed to in advance.

There is also a demand effect worth naming: patients paying out of pocket actively look for published prices, and a practice that publishes is findable by people who are already deciding.

  • Paid upfront rather than after adjudication
  • No claim submission, denial, appeal or resubmission
  • No patient balance to collect after the fact
  • Predictable revenue per service, known in advance
  • Discoverable by patients actively comparing prices

Where the maths works

A published cash price is frequently lower than a headline contracted rate and higher than what that rate nets after denials, write-offs, collection costs and the staff time spent chasing all three.

Whether the trade is good therefore depends on something specific to your practice: how much of your billed revenue currently survives that process, and how much you spend making it survive. A practice that collects promptly and in full on most claims has less to gain. A practice losing a meaningful share to denials, delays and uncollected patient balances usually has more than it expects.

The calculation worth doing is net revenue per encounter after collection cost, not headline rate — and most practices have never had a reason to compute it that way.

How to start without exposure

Publish a short list first: services you perform often, whose scope is genuinely stable, where you already know your true cost. Watch what volume arrives and what it does to your schedule.

Expanding from a working list is straightforward. Retreating from an over-broad one, having already published prices you cannot sustain, is not.

Check your existing payer contracts for most-favoured-nation language before publishing anything. It is rarely an obstacle, but it is much better found in advance.

What it does not change

Clinical decisions, scheduling autonomy, and your existing payer relationships are unaffected. Most practices run direct-pay alongside their existing contracts rather than in place of them, and the two do not interact except on the schedule.

Your obligations to the patient are also unchanged. A cash-paying patient is owed the same standard of care, the same records, and the same follow-up as any other, and nothing about the payment route alters that.

Which specialties this fits most easily

The fit follows how easily a service can be defined rather than how complex the medicine is. Imaging, labs, endoscopy, ophthalmology, orthopaedic procedures, dermatological procedures and most outpatient surgery price cleanly, because the work is repeatable and the scope is knowable in advance.

Care that is open-ended by nature fits less well. Chronic disease management, complex multi-morbidity and anything where the plan of care is genuinely discovered as you go is hard to reduce to a single number, and forcing it produces either an unprofitable price or a dishonest one.

This is not a hierarchy of value. It is simply an observation about which services have a stable boundary — and a practice can publish the ones that do while leaving the rest exactly as it is today.

Common questions

Do we have to publish prices for everything?

No. Practices typically publish prices for well-defined, repeatable services and leave complex or highly variable care out entirely.

What about patients who have insurance?

An insured patient can still choose to pay the cash price, and often does when it is lower than their remaining deductible exposure.

Does publishing a price undercut our payer contracts?

It makes a number visible that was previously not, which is why checking most-favoured-nation clauses first is worth the hour it takes.

See it for yourself

Every price on Mishe is public. You can check what a procedure costs, and which providers offer it, without an account and without talking to anyone.