Regulations regarding cash payments vary based on the nature of the business an NP practices under. Cash-only practices offer a number of perks, but it may be difficult to determine whether you are eligible to accept cash as a nurse practitioner. In many cases, providers must make a choice between accepting insurance or cash. However, there are some ways to operate a hybrid cash-insurance practice. Use this guide to learn more about protocols specific to private insurance carriers.
Understanding the specifics of your insurance credentials
Insurance-credentialed NPs who are employed through a private business are strictly credentialed through the practice that employs them. In these cases, individual providers are credentialed under their employer’s group NPI number. Because an NP’s insurance credentials are associated with the practice they work for, their credentials cannot be carried with them elsewhere. If a credentialed staff NP were to get hired by a different practice, their new employer would need to re-credential them under their group NPI. If the same NP were to establish their own practice, they would also need to become re-credentialed through the business they own.
How can I accept cash payments as a nurse practitioner?
If you are starting a side practice as a nurse practitioner, you can choose to accept insurance, cash, or both. Many NPs choose to strictly accept cash payments, and do not become insurance-credentialed under their LLC. This decision is mainly motivated by an unwillingness to navigate insurance-related red tape, and to get paid immediately upon date of service. If you do decide to become insurance-credentialed through your own LLC, the types of services you can accept cash payment for will be limited.
The key to running an insurance/cash hybrid practice is strategic billing. Here’s how:
- Bill insurance for covered services, like medically-necessary procedures
- Accept cash payment for non–covered services, like IV infusion, testosterone replacement, aesthetic procedures, and in certain circumstances, ketamine infusion
- Operate the “cash only” portion of your business under a separate legal entity (LLC)
Note: This protocol does not apply to medicare/medicaid plans. This guide can help NPs learn how to navigate these specific plans.
Some NPs operate an insurance-accepting general medicine practice and run a separate cash-only business in the same clinic with a different set of specialized services. (For example: an NP may operate a women’s health clinic that accepts insurance for basic gynecological services, while simultaneously offering cash-only aesthetic dermatology/injectable services in the same office.) When accepting cash payments for certain types of services, be absolutely sure that each service is indeed uncovered by a patient’s insurance plan. A simple call to an insurance carrier can verify coverage details.
99 Responses
Good info. Instead of doing a separate LLC could you do a DBA? For instance you have a primary care practice and want to open a weight lose clinic.
No, it needs to be a SEPARATE LEGAL ENTITY. A DBA is not that. It is just an extension of your already established legal entity that is accepting insurance. That would not work.
Just looking for clarification… Here you say if you have a practice taking insurance, you cannot have a cash based clinic using a DBA, but below you answered another individual saying you could do that?
Only if the cash based clinic is under a different LLC. You could do it as a DBA only if the service you are offering is a non-covered service.
Hi if you are waiting for the insurance to getting approved can you do cash only that time
Does the LLC need a separate NPI from my personal NPI?
Not if you are cash only! If you accept insurance, then yes… Cash though? NO!
Does being credentialed through insurance companies interfere with clients getting reimbursed when they submit for OON benefits?
To my knowledge, it shouldn’t.
Does it matter if you are credentialed by your personal NPI or group NPI for your primary care practice and open a cash only practice? if each practice has separate LLC.
For a cash practice, you would just function under your personal NPI. No need to worry about group NPI.
Considering having my psych practice with a side of weight loss offerings. I’m not able to dispense meds in my office. I’m primarily telehealth.
I’d like to be cash based only (not accepting Medicare but not opted out due to primary w2 employment).
If I’m cash based only, do I have to have separate legal entities for psych and weight loss?
If I’m taking 1-2 insurances, will they cover weight loss visits (99213, 99214)
Is it better to try just focus on psych patients and offer them some additional weight loss support as part of their overall treatment plan, or have a separate line of WL services?
1. You do not need separate entities for separate services unless you want to.
2. Insurance should cover the standard E&M codes. But if you are wanting to build the cash based arm of this pracitce, you would need a separate entity for that for covered services.
3. I think you should do both.
Can you create two separate legal entities( owned by the same person) and be credientialed under insurance for one and not credentialed under insurance for the other? I am thinking of opening a Medicare risk assestment (thus would need credentialing by insurance) main practice but wanted to be able to have a small cash side practice(would not take medicare patients). Now it seems I would have to have two separate legal entities to do this? What things could cover both to reduce costs? (EHR, insurance,)
Yes, that is exactly what you do as explained in the article.
You can have a lot of the back end operational stuff (EMR, insurance, payment processors) be for both. That isn’t going to make difference.
Justin – I think someone mentioned that the back end stuff like EMR etc should also be separate… But you think this isn’t necessary?
I dont think it is necessary
It absolutely needs to be separate. You cannot intermingle your notes or billing.
JustinAllan, thanks so much for the excellent information. I have a question that takes the discussion one step further… I am a private practice physician (practice owner with one other partner; under an LLC utilizing a group NPI number) that currently accepts a wide variety of insurances including Medicare. Would I be able to accept cash for select in-office procedures (that would normally be covered by insurance) by forming a new, separate LLC wherein all transactions (revenue and expenses) pertaining to the elective procedures would pass?
To my understanding: for Medicare no, because YOU are credentialed which is global for Medicare. For private insurance: Yes, you could do that.
Hello, I am an autonomous NP in Virginia. I work full time for a company seeing their employees and family members for acute issues and there is no dealing with insurance, it is just a service provided by the company to have me there. I worked for a corporate family practice clinic for the past 6 years which I was credentialed with all insurances, Medicare and Medicaid. I quit the corporate job by the way. Now I want to start my own practice and have just filed my LLC. I would like to offer some routine medical services, telehealth, weight loss program and aesthetics. I am stumped at how I should go about setting up payment for services. I know aesthetics would not be covered by insurances so can I just set up pricing and do cash for that service while accepting private insurances? Or should I start out as a cash based practice and then potentially be credentialed later for insurances?
I feel that my business will take off and grow substantially in my area once I open because of my reputation as a good provider and there is a great need for providers in the area.
Thank you for any advice you may give me!
Yes, if it is not covered you can charge cash for it. It is up to you…. credentialing will take 3-6 months, so if you want to start now just go ahead and do cash only.
I am a PNP opening a pediatric clinic. I am planning to accept insurance, but while waiting for credentialing/contracting am I able to accept cash payments to accelerate the opening of my practice?
Yes you can, but you will be wasting your time. Just wait until you are credentialed.
I own & am credentialed with all commercial insurance, Medicaid & Medicare for psych. I’m dual certified FNP/PMHNP
I have an S Corp… if I want to add cash pay weight loss can I do this as a DBA?
Yes: The DBA (Doing Business As) and its Marketing Implications in the Nurse Practitioner Business
Thank you Justin for always providing insight. I’m a Psych NP. I am getting credentialed at a clinic I’m a 1099 at and I’m opening a cash pay practice LLC (just me). Based on your article, I should be able to accept insurance patients, even if I’m credentialed with them through my 1099, with the exception of Medicare and Medicaid. I was planning to have my 1099 pay me through my LLC which I was planning to use for both my 1099 AND LLC. Is that ok to do or should the 1099 pay me directly to avoid any insurance issue?
Just form another LLC for the 1099 or the clinic. It isn’t that difficult to have two LLCs.
Thank you Justin for the wonderful insight. I was wondering if I have a primary care clinic that accepts medicare it sounds like I could also have a cash based Telehealth practice if I build a separate entity for it. I was planning to make a virtual urgent care Telehealth. My question is will I be able to offer my primary care patients this service or would that be considered self referral since I own both businesses?
If it is a totally separate entity then you should be fine. But yes, I would think this would be considered a self referral and a BIG no with Medicare
It’s me again.
After a while of trying to be cash based only (cash rate was 300/ 150, now higher that I’m taking ins)…. I am now seeing psych patients with commercial insurance via third party companies (Grow Therapy and Alma) and am directly credentialed with two smaller insurances.
I’ve been doing some medical weight reduction with my psych patients, both in the same visit. Many are paying cash for the prescription products. PAs were a headache, and rarely approved. Now, supply issues have made it difficult for most. I’m finally brave enough to start offering compounded meds as an option. I have a pharmacy I feel comfortable enough to start with compounded. I have the option of the patient paying the pharmacy direct, or I pay the pharmacy (discount which I can mark up).
1. Should I create a cash pay “package” for weight loss services (within my current LLC that also sees MH pts) where I purchase the meds and the pharmacy ships to the patient, and the patient pays me for the package (visit, meds, follow up)
2. Should I create a separate LLC for cash only medical weight reduction and maybe eventually TRT?
3. Right now I rent out a small office for my LLC. I don’t have a separate entrance, or separate exam room.
1. Yes, that is the best way for profit. 2. Yes, separate LLC for cash services 3. I wouldn’t worry about it… I doubt anyone would come look.
I am in a very similar situation and would love to talk/consult with you on lessons learned. Or Maybe Justin, you have a recommendation(s). We currently accept insurance and several of the PMHNPs prescribe GLP1s along side the psych meds. I am new to the practice and will be offering the wt loss/wellness services which will be cash pay. But the owner is concerned about no longer offering established patients the insurance option on the wt loss meds. Could/Should we offer GLPs Cash and Insurance? Many of these pts just pay direct to the pharmacy for the medication. It might be a bit of an adjustment for them to see me and only have cash option. I will be credentialed with the practice and could run their visit through insurance. Interested how to approach this and how to market it going forward.
Sure, offer it on a cash based basis. As long as it isnt covered by insurance, you can charge cash for it.
I suppose a slip and fall insurance policy for a second cash pay entity would be needed as well.
We are a private pediatric office starting to offer semaglutide to our over 35 BMI patients with comorbidities. We are concerned that prescribing semaglutide and having them pay cash for the medication would cause our insurance companies to drop us. We are contemplating staying one entity or making weight loss a second entity. We are currently one MD and myself, a PNP. If just I did the weight loss portion under my NPI, would a second entity be needed?
Thank you sooo much for this great information!!
For a cash based weight loss program, I would operate out of a separate entity
Hello Justin, thanks for this valuable information. I’m slow- sorry about that.
QUESTION: I am starting a psychiatric nursing corporation (PC) and will work with Alma/Headway for billing. To see psychiatric cash patients (no insurance), do I need an NP2? Or with my NP1 is fine? Or how can I do that if these patients won’t be run by Alma/Headway? What would be the easiest way? Thanks in advance.
Just your normal NPI because headway will be doing the billing for you.
Hi, I am starting with Grow therapy (accepting insurances) for my Psychiatric patients. I will be credentialed under their NPI and is not credentialed individually. I want to also have an integrated medicine in which I am only accepting cash clients. I have 1 LLC that I use now since I am 1099 that I switch to an S-Corp. Will I need to get another NPI and LLC for my integrative psychiatry medicine cash pay or can I just use my own NPI and LLC? Thanks
Just use your own NPI and LLC. No need to complicate this if you have a 3rd party doing all your billing
Thank you so much for that info. Also, I am licensed in 3 states and wish to prescribed controlled substances in all 3 states. However, the DEA states that I need physical practice addresses in order to get a DEA number. Do you know how that is possible?
Literally just have to find a physical address in those states… shared office space for example
Thanks
This article has been so helpful! Could you clarify if it is possible to work in an out of network practice part-time that submits superbills on behalf of clients while also working part-time at another practice that is credentialed with insurance? I understand that both companies will have different NPI numbers. The difference here from the examples you have provided is that the out of network practice isn’t cash only.
Yes you can do that
To clarify:
If you are credentialed/ in-network with a private insurance (non-Medicaid/medicare) with W2 employment and while awaiting for credentialing for a start up private practice- Can you accept cash /self pay without risking your “in-network” credentialing at your w-2 employment?
Hi Justin,
Thank you as always for your great information. I started a telehealth weight loss business as a FNP, Sept 2022, very slow growing but now I have about 50 patients. I started doing cash only for compounds, added prior auths and insurance patients for 100.00 a month, and then became credentialed for 3 insurances. I’ve been doing my own billing since I don’t have a lot of insurance patients. I didn’t mind the slowness since I was finishing my Psych NP as well as working full time teaching.
Now I want to add psych and here are my questions on how to go about this:
1. I’m interested in doing integrative psych practice so I can utilize everything with hormones, psych, weight loss, etc. I would operate cash only and then keep the same LLC. My DBA is Scale Down for the weight loss. Should I add another DBA with psych name or just can add wellness services to my original DBA?
2. If I just stick with cash only, I want to cancel my contracts for the insurances. Can you get recredentialed at any time, in case you want to accept insurance again?
3. I could do both, but then I would have to make a new LLC, and would I do all 3 states, or just start out with one state and go from there? I also had to get 2 bank accounts linked to my LLC (long story) so I’ve been putting insurance payments in one account and cash business in the other account to keep them separated. If I get another LLC, do I have to open a third bank account?
Sorry for all the questions, I just want to choose the easiest solution 🙂 Thanks so much!
1. I would do the DBA with the psych name
2. Yes
3. Just start with one state. And you need a separate bank account for each LLC
Thank you for all this information. I am a PMHNP, and I have a Psych LLC in-person and virtual company that is credentialed with all insurances. I desire to have an integrative psychiatry business where I only pay cash. What do I do?
Literally just follow the steps in the article. Form a separate entity etc….
I own a RHC and want to start a cash based weight loss clinic. I’m having issues with a name for the WL clinic to register as a separate entity. Is it feasible to use my regular clinic name in the name of my cash clinic? or does that make things messy so to speak? For ex: New clinic name @ RHC name or dose it need to be something completely separate and not connected?
I would make it something separate as to not comingle the insurance business with the cash
If I work at an out of network clinic that submits claims on the patient’s behalf, does that mean I am credentialed with insurance? I have worked at other clinics that did take insurance, not sure if that matters? But my current clinic is out of network only. I am want to see clients my own on the side and I want to provide them with a superbill, but I am unsure if i can use my individual NPI number or not. I don’t have an LLC, I was going to start just as sole P until I build a case load.
You are crednetialed as a single provider but if you open a cash based practice, your entity isnt so you are fine
Hello. We are a new mental health clinic cash pay only for ‘packages’ that include the mental health evaluation and prescriptions sent to their home. We will provide a super bill for the clinical appointments. If we decide to get credentialed through insurance, can patients opt to pay cash? We often run specials for new patients, etc. If we take insurance, how does that change what you are able to advertise as the cost of your services?
They can pay you cash if they want. You can advertise whatever you want… insurance doesn’t dictate that. But you are “supposed” to bill insurance for covered services
Do you provided 1 on 1 consultations regarding this topic. I have so many specific questions
You can ask questions here or email us
Thank you Justin!
I am just starting my telepsych practice for Medication management as well as therapy. Cash pay only right now. I was recently asked by one of the surgeons if I could do the pre-surgical psych evals for spinal stimulator implants and bariatric surgeries. I know I’m capable of doing them, but do you think I would have to bill through insurance for those? Since it is the insurance companies that are requesting the pre-surg psych exams? Simply put, with a separate LLC, could I do cash pay for everything in my practice, except for the pre-surgical psych evaluations?
yes, you would need to use insurance for this as patients will expect it and will not want to pay out of pocket for it.
Hi, two questions here: 1.) if I work full-time for an insurance participating clinic and then want to establish a cash-based telemedicine practice do I need a separate NPI# for the LLC? 2.) I also have a contract 1099 job that I do part time, can I get paid through my LLC with that contract position also, or I should I get paid directly as myself from that contract work?
Yes, just have your LLC paid as a contractor. That is fine.
Do I need a seperate NPI for my PLLC?
Only if accepting insurance
Hi, Justin,
Here are the facts: I work at a hospital and am enrolled in Medicare under my individual name (entity type 1). I want to open a cash pay business (LLC) which I am the sole provider in. If I open the cash pay business and enroll in Medicare under the business (entity type 2), then opt out, does that affect my entity type 1 enrollment at the hospital? In other words, if you opt out under one, does it make you opted out for both? Thank you!
Yes, if you opt out you opt out as a provider. So you cant opt out under a different entity. It doesn’t work like that. Its all or nothing.
Hello,
Great article, thank you for writing this. I am an individually-contracted provider at a psychiatric outpatient clinic and would like to open a separate cash-pay clinic for therapy services since reimbursement for therapy is bad but I like providing that service for interested patients. Since I’m individually contracted, I created a PLLC so that I could get set up as an S-Corp to maximize tax benefits. If I started this cash-pay therapy business, would I need to create a NEW and SEPARATE PLLC? Or since I would not be operating under that outpatient clinic, could I use the same PLLC?
I would suggest forming a separate entity for a cash based business.
I have just opened a behavioral health clinic, partnership. My partner is a PA and wants to accept insurance and I am a NP and decided that I want to operate cash pay only. Our practice has already been credentialed with a couple carriers. Is is possible to figure this out? Could I operate under my own NPI/EIN/LLC and just not bill out of the practice LLC? I don’t want to get in a legal mess. Thank you for your advice!
Just form a separate LLC and keep it separate from the operating LLC that has insurance. Thats pretty much it
Hi,
I am a FNP. I work for a Hospital as a W2 employee, but also provide services with them for 1099 income through my LLC. I am credentialed with insurances for both services, billed by the hospital.
I am interested in starting telemedicine services, primarily for Medicare age group. I would be charging a monthly membership fee (to my understanding Membership fees are not covered by Medicare so there should be no issue with that). But I would not be charging any other fees to these patients, only my membership fee. Since I am not charging any fees for services covered by Medicare, will it be ok to run through my current LLC? And would it cause any issues for the hospital billing for my services under their group NPI?
You cannot bill cash to medicare patients if it is a covered service, so it deppends on what you are offering in that membership… Word of caution: people with medicare will generally NOT want to pay cash for medical care. They are on a budget.
Do we need a 2nd EIN number for tax purposes with the cash based side if we already have to separate LLC’s?
Hey there… Dual Cert FNP/PMHNP….Only provider, just me…
State of Arizona…I have a PLLC that I haven’t done anything with it for 20 months
Now, I am a bit of a mess…
Signed up with Alma (who will use NP1)
Also just took a 1099 position (this is new to me) and….am
Working on opening my own practice (Integrative psych) which I will get an NP2 for private insurance; I will not take Medicaid/Medicare. Will expand to do more thyroid/hormone optimization and weight loss…
1. How do I report the 1099 contract work, that has nothing to do with my own practice I will be opening next year? Its currently under my name/SSN but I am not sure this is the best thing. Perhaps it should be going to my PLLC? Should I form a second PLLC/LLC instead and keep it separate for contract work?
Thanks in advance.
The income just flows into the LLC you contracted out the 1099 position for and you use that income for business expenses.
Hi Justin,
Thanks for all the help in the above questions. I have a question of my own and would appreciate your insight. I’m a primary care physician opening up my own family medicine clinic and will be credentialed under insurances there. I would also like to open a separate cash-based weight & wellness practice where I offer things like compounded GLP-1, body composition scans, etc…
1. Based on what you’ve said, does that separate cash-based clinic have to be its own LLC?
2. Even if I don’t accept Medicare patients in it, does that separate cash-based clinic only have to offer non-covered services?
3. If I wanted to create a “weight loss bundle” in the cash-based clinic (includes cost of generic/brand prescriptions sent to pharmacies, office visits, etc), can I still do that? Or would the prescriptions be considered “covered services?”
Thank you!
1. Yes
2. No
3. Yes thats fine, its a concierge practice and they are paying you for those services.
Hi Justin,
Another super helpful article. I have a few questions after reading. I am a 1099 contracted NP at a private general psychiatric practice Mon-Thurs, and I want to open a side telemed business operated on Fridays to see cash-pay clients looking to do integrative/functional psychiatry and therapy. Suppose I am credentialed with an insurance carrier through the private practice’s NPI and NOT through my LLC that I get paid through — can I accept cash-pay clients for my telemed business since I won’t be pursuing insurance paneling through my business and NPI for that?
Thank you for any insight!
Yep, because that entity isn’t going to be credentialed.
Now I am little confused with the last one you commented regarfing NPI. So:
Cash based clinic with different LLC- no need to separate NPI
Insurance based clinic- need separate LLC?
Yes, insurance needs a separate LLC with a group NPI
Hi Justin,
I am dual ANP/PMHNP. I have a private practice seeing psych patients (telemedicine). My LLC is credentialed with insurances.
I want to start a cash only practice (weight loss, hrt). Do I need to form a new LLC for the cash only practice or can I do a DBA under the old LLC?
Hi
I am ANP/PMHNP. I have a psych side practice where I accept insurance. My LLC is credentialed with insurance companies. I want to start a cash only niche practice. Do I need to form another LLC or can I do DBA that accepts cash under my current credentialed LLC. Thank you!
Hi Justin, I am a FNP in NJ, credentialed for private, medicare and medicaid, where I work in post acute care LTC center. I just formed my LLC and want to start an aesthetics/iv vitamin infusion/func med/wt loss/hrt cash based mobile practice. Is there anything I have to worry about with any functional med services? I am going to be taking your foundational course.
You shouldn’t have to as long as your LLC isnt credentialed. Most of those services are altnerative in nature and not covered
Hey Justin!! I am JUST getting started. I live in California, and as you know, NPs need an overseeing MD for a certain amount of hours to be able to apply to be solo. I am a soon-to-be PMHNP, and I was wondering if I could get/apply for my RN license in another state, say Arizona, along with my NP license for the said state, and function as a telepsych clinic out of Arizona while living in California. Also, can I help patients from any state of Arizona’s telepsych clinic? What are the rules regarding that? Also: the LLC situation. What is better, a S Corp or LLC? If you start with LLC, is it easy to transition to S Corp later? Also, about the interstate DEA questions someone asked, you said to find a shared office. But like, what do you mean? Say this is my Arizona telepsych clinic; I don’t have a shared office space in AZ with anyone; how can I get a physical address to get the DEA number?
Also: can you use the same EMR system and billing service for both cash and insurance patients? Also, (lol) I am reading some NPs saying they are “credentialed.” What does this mean, and why do we have to get credentialed or apply to each individual insurance provider in order to accept patients who use that insurance???
Sorry, I am still a baby BSN RN working on my NP, and I just bought your bundle training package for start up! I want to have a telepsych hybrid with integrative treatments like TRT, GLP-1, and ketamine infusions. (Ketamine later when I can open in California) THANK YOU!
1. You can apply for a license in any state you want and see patients there.
2. Just start with an LLC. No specific rules.
3. You can file as an s-corp later for tax purposes if you are a making 50k+ in profit.
4. You just need a physical address in the state you are apply for a DEA license in. The DEA Needs to be attached to a physical address.
5. Same EMR is fine
OH also!!! Can I start the LLC or S Corp now??? Or wait until I have my license, lol! thank you!
Just start it
I am starting my own cash based practice (sick visits, hormones, med refills, telehealth, all the things) after working with a primary care up the road that I was with for several years (and building a huge following). I am planning on not taking Medicare patients so I don’t have to opt out however would I still be able to take tricare/ private insurance patients cash pay for COVERED services without jumping through the hoops of opting out?
Ya thats fine, just don’t see Medicare patients
Hi Justin, I bought your how to start your own psych practice course and have followed it to a T. I am a month away from opening. I formed my LLC and am going to be a cash based business for psych evals and medication management follow ups. I don’t want insurances dictating how I practice. However, I want to get credentialed to be able to offer Spravato for treatment resistant depression to those that need it. Forgive my ignorance. I’ve read several of your articles as well. Can I run my cash based psychiatric practice and only run Spravato through insurance? All under the same LLC? Based on what I’ve read it appears I would need a separate LLC for insurance?
Ya thats fine
hi! can you be credentialed with a couple of insurances through Headway and then accept cash payments for rest of patients under same PLLC?
I don’t see why not because your entity isnt credentialed… you are just using the Headway credentials technically.
Hi. If I will do cash pay under a new LLC, but will use my personal NPI. When the patient bills the insurance, my superbill will include my personal NPI, which insurance might associate with my prior contract. Then, is it better to get a second NPI for the new LLC? Thanks!
They don’t care about your personal NPI, only the group NPI that is credentialed
Does Medicaid function like Medicare as for as opting out. I understand if opting out of Medicare (it is global). But what about Medicaid? Could a provider working for one entity be able to bill Medicaid and still work at another entity that is set up as private pay.
This is in Louisiana if it is state specific regulation.
It is state specific unfortunately. Most states don’t follow the Medicare guidelines though