Why Cash-Pay Surgery Programs Should Collect Deposits Before Consultation; Not After

As a leading expert of cash pay program development for surgeons and ASCs, I am frequently requested to provide examples of best practices.

Cash-pay surgery is gaining traction as patients increasingly seek transparent, affordable alternatives for medical procedures outside of traditional insurance models. One critical aspect of managing a successful cash-pay surgery program is determining when to collect fees and deposits from patients.

This form is what I use to document the terms and conditions of the visit and the fee, along with the non-cancellation after the fact that I supply later in the article.

Patient [Patient's Name] presented for a one-time case acceptance consultation on [Date] via [in-person/telehealth]. The purpose of this consultation was to review the patient’s medical history, current condition, and potential candidacy for the recommended procedure.

During this consultation, the patient was informed that treatment has not begun. The consultation was limited to case review and evaluation to determine whether the patient is a suitable candidate for surgery.

It was clearly communicated to the patient that no further care or treatment will be provided until:

1. The patient accepts the terms and conditions of the proposed surgical procedure.
2. All surgical fees are paid in full as agreed.

Patient was advised to contact the practice with any further questions and was provided with a copy of the proposed treatment plan, fees and payment due dates, and consent form for surgery.

Physician’s Signature: ________________________ Date: ________________________

Before you involve a surgeon and begin investing time in surgery scheduling, lab tests, and more, collect your telehealth or initial consult early in the process to safeguards both the surgery center and the surgeon, ensuring there is financial commitment from the patient and clarity around the responsibilities of care.

Create a written quotation based on the INITIAL CHIEF COMPLAINT, not on a surgical diagnosis. Until the surgeon has read any imaging studies and reviewed the patient's history, you only have a chief complaint (knee pain, recurrent dislocation of the patella, etc.), Once the surgeon becomes involved, other legal responsibilities arise. One is assumption of and duty of care.

Ensure that you collect in full for the telehealth prior to providing the link for the meetup or an appointment time. Be prepared to provide a receipt. No payment, no appointment. The appointment is the gateway to legal responsibility for continued duty of care unless you document that this visit was a one off.

The Timing of Deposit Collection

When running a cash-pay surgery program, the ideal time to collect a deposit is at least two weeks before the surgery date. In the USA, the payment needs to clear so that the surgeon, CRNA and assistant can be paid from package proceeds. This is an IRS rule, not Maria Todd's rule. This also ensures that the package seller avoids potential legal pitfalls, including being held liable for providing a standard of care (duty of care) before the patient has committed to the financial terms of the procedure.

In my most frequently established model, a case acceptance appointment deposit—typically around $375 or more—is payable in advance of the consultation. This deposit serves as a financial commitment from the patient and covers the surgeon’s time for reviewing the case and determining whether the procedure is appropriate. If the patient no-shows or cancels without adequate notice you can choose to keep some or refund it all. Your choice.

I now add the following statement to the invoice for the case acceptance appointment confirmation and payment receipt:

Acknowledgment of Payment Policy

I, [Patient’s Name], understand and agree that the payment I make for my medical consultation and related services on [Date of Visit] is final. I acknowledge that after the completion of the visit, I may not dispute or request a chargeback of the payment with my bank or credit card company. I agree to these terms as a condition of receiving this one time medical service.

Patient Name: ______________________ Signature: _______________________ Date: ____________________

Why Deposits are Crucial Before Duty of Care is Established

One of the key legal considerations in cash-pay surgery is the concept of duty of care. Duty of care refers to the legal obligation a healthcare provider has to provide treatment that meets the standard expected within their field.

Once a doctor-patient relationship is established, the surgeon is responsible for the patient's care and well-being. If the patient fails to follow through with surgery or opts for treatment elsewhere without clear documentation, the physician could be exposed to claims of patient abandonment, which could have significant legal consequences. Mark the chart appropriately if the patient cancels, or delays care, or ceases to follow through. If you've already established a relationship, do the "30 day letter" but you can shorten the time

To avoid this, it is important that the case review is clearly documented as an initial consultation for case acceptance—not the beginning of treatment. By requiring a deposit upfront, the practice is also securing payment for the work the surgeon performs, even if the patient chooses not to proceed with surgery.

The Benefits of Requiring an Early Deposit

1. Financial Commitment: A deposit shows that the patient is serious about undergoing the procedure and helps filter out those who are not ready to proceed. It reduces the number of consultations that result in no surgery, saving both time and resources for the practice.
2. Covers Physician Time: Even if the patient does not go forward with the surgery, the doctor is still compensated for the time and effort they put into reviewing the case and providing recommendations. This ensures that no time is spent uncompensated.
3. Clarifies Expectations: Collecting a deposit and documenting the initial consultation as a case review creates clear boundaries regarding when the doctor-patient relationship begins. This protects the surgeon from liability and allows them to focus on patients who are committed to undergoing surgery.
4. Avoids Patient Abandonment Claims: Without proper documentation, if a patient decides not to proceed, the physician could be accused of abandoning the patient. An early deposit combined with clear documentation of the nature of the consultation helps avoid this risk.

When to Provide a Price Quote

A key point in cash-pay surgery is that a final price cannot be quoted until the doctor has reviewed and accepted the case. This is because the exact nature of the procedure often cannot be determined until the surgeon has evaluated the patient's needs. Once the case is accepted, the surgeon specifies what will be done and provides an accurate quote. However, by this stage, the surgeon’s time has already been compensated via the initial deposit, protecting their financial and professional interests.

A few words on if the patient does not follow through after the initial consultation.

To properly document the termination of a doctor-patient relationship, it is essential to follow specific steps to ensure the process is legally sound, protects both the physician and the patient, and avoids any claims of patient abandonment. Here’s a guideline for effectively documenting the termination:

1. Written Notice to the Patient

The termination must be clearly communicated in writing. A termination letter should be sent to the patient outlining the following key points:

• Reason for Termination: Provide a professional, non-judgmental explanation (e.g., non-compliance with treatment, abusive behavior, or non-payment, their decision not to move forward, if applicable).
• Effective Date of Termination: Specify the date on which the doctor-patient relationship will formally end. If the patient advises in writing that they don't intend to go forward, you can use that date as the notification date. Still send the letter to be safe and formally close the case.
• Ongoing Care: If the physician will not be providing ongoing care past the initial telehealth consultation, say so. Otherwise, state that the physician will continue to provide care for a limited period (e.g., 30 days) if necessary, to allow the patient time to find a new provider. During this time, care will be provided only for urgent or emergency needs. After the clock runs out, you're done.
• Referrals: If you only did the case acceptance telehealth for an out of town medical travel patient, you don't have to invest more time researching where they can get alternative medical care or provide a list of alternative providers or suggest the patient consult their insurance network or state medical board for referrals. This is especially true if the patient advised you they are terminating the relationship.
• Transfer of Medical Records: Offer to transfer the patient's medical records to their new healthcare provider upon receiving the appropriate authorization. If you only reviewed records provided to you, and didn't create other than an Order for Surgery and a brief history of info taken during the call, mark the case cancelled and you are done. If they need the telehealth note for taxes or reimbursement, fair enough. Send what YOU CREATED. You don't re-release medical records from someone else.

2. Delivery of the Notice

• The letter should be sent via certified mail with a return receipt requested. This ensures there is a formal record that the patient received the termination notice. If you don't know where they live, send it to the last known address. It should forward or be returned. The point is, you tried.
• A copy of the letter should also be kept in the patient's medical file.
• Optionally, the letter may also be sent via regular mail or delivered in person to ensure redundancy. I always do BOTH.

3. Documentation in the Medical Record

In the patient’s medical chart, document the following details:

• The date the termination letter was written and sent.
• The method of delivery (certified mail, in-person, email, etc.).
• A brief summary of the reason for termination, but be concise and factual. "Patient notified us of his intent not to move forward as scheduled."
• Any further communication with the patient after the notice was sent, including follow-ups or patient inquiries.
• Documentation of any referrals or recommendations made to assist the patient in transitioning to another healthcare provider, if any.

Example chart note:

"On [date], termination letter sent to patient via certified mail. No further appointments are planned/scheduled. Awaiting signed authorization for medical record transfer."

4. Final Interaction Documentation

If there are any further interactions with the patient during the transition period (e.g., follow-up calls, urgent visits), document these interactions carefully, including the nature of care provided, any referrals given, and the patient's response.

1. Keep a Copy of the Patient’s Email Attach or store a copy of the patient’s email in their medical record. This ensures you have documentation of their intent to terminate the relationship, protecting you from potential liability.
2. Offer to Transfer Medical Records As part of your acknowledgment, include instructions for how the patient can request the transfer of their medical records to the new provider. Typically, this requires a signed authorization form. Document any requests to send records and when the records were sent.
3. Close the Chart Once the patient has confirmed they are moving to another provider, and you have documented the exchange and transferred the records (if requested), you can close the patient’s chart, indicating that the relationship has been formally terminated.

Additional Considerations:

• No Further Responsibility: Once the patient clearly indicates that they are transitioning care and you have acknowledged their request, you are no longer responsible for their ongoing care, provided that you have not left them without urgent or necessary medical support during the transition.
• Patient Abandonment: Since the patient initiated the termination, this does not constitute abandonment, especially if you have offered to assist with medical records and potential urgent care during the transition period.

If you need help setting up a cash pay surgery program, please reach out. (800) 727-4160.