SimpleCare: Innovative doctor-patient network shows billing doesn’t have to be complicated—or unfair

Dr. Vern Cherewatenko simplified his medical practice and helps other physicians do the same, so that their cash-pay patients can benefit.

Around the turn of the millennium, this physician in Washington state started searching for a simpler, more profitable way to run a medical practice and for cash-pay patients to be treated more fairly. His former $6 million practice with 30,000 patients went bankrupt in 1999. He blames that on the way health insurance and government entitlement programs reimburse—or fail to properly reimburse—health care providers.

He created SimpleCare, a network of doctors who set separate prices for cash-pay patients who also are members of the network. The types of physicians who have gotten involved in SimpleCare are across the board: family doctors, neurologists, cardiologists, surgeons, massage therapists, dentists, and chiropractors, just to name a few.

Membership costs $50 per year for doctors after a $125 initial fee. They get a listing on the simplecare.com web site, which helps patients find them.

Patients pay $29 annually for an individual membership or $39 for a family membership. That qualifies them for the cash-pay prices offered by SimpleCare doctors.

About 1,500 doctors have signed on, and more than 60,000 patients. The latter are able to find the former at simplecare.com, which has a search function according to location and specialty.

Doctors in SimpleCare are free to charge reduced fees to patients in the network, even if it’s a different price from what insured or Medicare/Medicaid patients are charged. That’s because SimpleCare uses a different, and much simpler, coding system for billing. By using a unique coding system for cash-pay patients, doctors don’t violate insurance or government rules. Instead of the 7,500 codes in the American Medical Association’s CPT (Current Procedure Terminology) publication, SimpleCare has five, all of them related to the length of a patient visit: brief, short, medium, long, and extended. Doctors can then base charges on the time they spend with a patient.

“A brief visit, a ‘B,’ totally derails the insurance company, so people can’t even bill that to an insurance company,” Dr. Cherewatenko says.

Doctors are also free to bundle whatever services they want. For example, a cardiologist could create a “Men’s Checkup” bundle, say $400, that could include an EKG, treadmill test, bloodwork, medical history, or whatever else he wants to include.

Doctors in SimpleCare are free to charge reduced fees to patients, even if it’s a different price from what insured or Medicare/Medicaid patients are charged.

“It doesn’t have to be so complicated,” the doctor says. “You don’t have to check a patient’s eligibility. You don’t have to do 20 or 30 things, if a person is paying cash. We can just do the medicine and don’t have to do the defensive insurance posturing.”

Dr. Cherewatenko says he found that “many people were being penalized when they couldn’t afford insurance, and they were paying cash. They were paying premium or retail rate. That’s what the cash-paying patient gets presented with when he gets a bill from the doctor, and he doesn’t have health insurance.”

Doctors were—and are—being penalized, too, when being paid through insurance.

For example, when Dr. Cherewatenko used to charge $79 for a 10-minute office visit, the patient’s insurance company would only pay about $43 of that. In the meantime, processing the claim cost the practice about $20, leaving Dr. Cherewatenko $23 to pay an overhead of $30.

Now he charges $50 for the same visit, saving the patient $29 and making a profit in the process because he has eliminated processing costs.

And despite not accepting insurance, Dr. Cherewatenko’s practice still attracts some patients who have insurance.

“They choose not to use it because they don’t want the hassle, either,” he says. “We’ll do an insurance bill for them, if they want it. We’ll circle the codes that they need. But we’ll charge them a little extra to do that.”

SimpleCare also makes it easy for doctors like Cherewatenko who want to emphasize wellness and natural approaches, which insurance rarely, if ever, covers.

“I’m a board-certified family doctor, but I practice lots of holistic, integrative medicine, so many times insurance won’t pay for that anyway,” says Dr. Cherewatenko, author of the books The Diabetes Cure and The Stress Cure. The former looks at the role of obesity in diabetes and the latter at the impact of hormone levels on stress.

“I used to treat a lot of obesity and the insurance companies wouldn’t pay for obesity treatment,” he says. “I got pretty frustrated because a lot of these patients really needed help.”

To get them that help, Dr. Cherewatenko would point out that their obesity also was causing high blood pressure, high cholesterol, back pain and depression.

“You’d better have something wrong with you, or you can’t bill the insurance company,” Dr. Cherewatenko says. “It’s really sick care, not health care. We have a wellness approach to things. We teach people how to be healthy and stay healthy.”

Pretty simple.