One contract, cash for everything else: picking the one that stays

Which contract should stay?

The one your patients cannot replace. Rank every contract you hold by two things: how many of the visits you want to keep arrive through it, and what its members' plans pay for those visits once you are out of network. A payer filling a large block of your schedule with members whose plans pay nothing outside the network is an anchor. A payer sending four visits a month is a rounding error with paperwork.

No regulator or public dataset sets the share at which a payer becomes worth keeping. That threshold is a judgment about your own book, and the framework here is one way to reach it, not a standard anyone publishes. The second test is easier, because what a plan pays out of network is written down, and most of the money sits there.

Call the one that stays your anchor contract. No payer uses the word and it carries no legal weight, but it names the participation agreement a hybrid practice keeps while the rest of the schedule moves to cash.

What a patient's plan pays when you are out of network

Often less than the phrase out-of-network coverage suggests, and sometimes nothing. A plan built on a provider network is permitted, not required, to leave out-of-network cost sharing out of the ACA's annual limitation on cost sharing 1Ref 1U.S. Department of Health and Human Services (2013).§ 156.130 Cost-sharing requirements..Supports the point that a network-based plan is permitted rather than required to count out-of-network cost sharing toward the ACA annual limitation on cost sharing, so a plan that nominally covers out-of-network care can leave that spending uncapped for the patient.. A patient can hold a plan that covers out-of-network care, pay your cash price, and have none of that spending counted toward the cap that would otherwise stop it.

The regulation's own words are narrow: cost sharing paid by, or on behalf of, an enrollee for benefits provided outside of such network is not required to count toward the annual limitation on cost sharing 1Ref 1U.S. Department of Health and Human Services (2013).§ 156.130 Cost-sharing requirements..Supports the point that a network-based plan is permitted rather than required to count out-of-network cost sharing toward the ACA annual limitation on cost sharing, so a plan that nominally covers out-of-network care can leave that spending uncapped for the patient.. Nothing there forbids a plan from counting it. The plan simply does not have to.

The money a patient brings to that choice usually starts behind a deductible. In KFF's 2025 employer health benefits survey the average general annual deductible for single coverage was $1,886, a figure KFF described as similar to the year before 2Ref 2KFF (Kaiser Family Foundation) (2025).2025 Employer Health Benefits Survey.Supports the 2025 survey-average general annual deductible for single coverage and KFF's own description of it as similar to the prior year, framed strictly as a national employer-market average rather than any individual patient's figure.. That is a national average rather than the number on any patient's card, but it sets the scale a cash price competes against.

Count the plan types your own patients carry at intake, starting with the payer you are thinking of dropping.

Rank the candidates on your own book

Pull twelve months of your own data before you look at anything published. For each contract you hold, fill five columns: share of visits, share of collections, the plan types those members carry, the contracted rate for the two or three codes you bill most, and the notice you owe to terminate. The ranking falls out of the third column meeting the first.

Rates are half of what a contract does. Timely-filing windows, amendment-by-notice clauses, the term, and the notice you owe to terminate without cause all sit in the document, and reading a payer contract closely is how they get into the fifth column.

Visits and collections often rank different payers first. A payer can fill a fifth of the schedule and produce a tenth of the money, and letting that one go buys back more calendar than it costs in revenue.

Compare each contracted rate against what the visit costs you to deliver. The price floor comes out of your own cost per hour of clinical time, and a rate underneath it loses money at every visit, whatever share of the schedule it fills.

But volume can still outrank the rate, because an empty calendar collects nothing at all.

Check the outside market before you commit

Two free state-level datasets tell you who dominates locally. KFF publishes the enrollment and market share of the three largest insurers in each state's ACA individual market for every year from 2013 through 2024, built from the insurers' own regulatory filings 3Ref 3KFF (2024).Market Share and Enrollment of Largest Three Insurers - Individual Market.Supports that a free, methodology-documented state-by-state indicator reports the enrollment and market share of the three largest insurers in each state's ACA individual market from 2013 through 2024, built from insurers' own MLR regulatory filings, as one input to an anchor decision.. A matching indicator runs the same calculation for the small-group market, with enrollment measured in life-years 4Ref 4KFF (2024).Market Share and Enrollment of Largest Three Insurers - Small Group Market.Supports the small-group-market counterpart of the same indicator series and its life-year enrollment measure (member months divided by twelve), as the equivalent lookup for a practice whose patients carry small-employer coverage..

But neither indicator answers your question by itself. They cover two market segments and not the large-employer plans many of your patients carry, and neither prescribes a share at which a payer becomes an anchor. They work as a check against the state: a payer holding a fifth of your schedule and a third of your state's individual market is a different proposition from one holding a fifth and shrinking.

Being listed by a Marketplace plan also puts you inside an apparatus built to keep you findable. The statute behind Qualified Health Plans requires an issuer to ensure a sufficient choice of providers and to give enrollees information on in-network and out-of-network provider availability 5Ref 5U.S. Congress (Patient Protection and Affordable Care Act, Pub. L. 111-148, title I, § 1311) (2010).§18031. Affordable choices of health benefit plans.Supports that a Qualified Health Plan issuer must ensure a sufficient choice of providers, disclose in-network and out-of-network provider availability to enrollees, and include essential community providers serving low-income, medically underserved populations where available.. The same subsection requires the network to include essential community providers serving low-income, medically underserved populations where available 5Ref 5U.S. Congress (Patient Protection and Affordable Care Act, Pub. L. 111-148, title I, § 1311) (2010).§18031. Affordable choices of health benefit plans.Supports that a Qualified Health Plan issuer must ensure a sufficient choice of providers, disclose in-network and out-of-network provider availability to enrollees, and include essential community providers serving low-income, medically underserved populations where available.. Out of network you sit outside that machinery.

Medicaid and Medicare decide themselves

Neither program behaves like a commercial contract you can simply let lapse. A Medicaid-participating provider must accept, as payment in full, the amounts paid by the agency plus any deductible, coinsurance or copayment for a covered service 6Ref 6Centers for Medicare & Medicaid Services (2013).§ 447.15 Acceptance of State payment as payment in full..Supports that a Medicaid-participating provider must accept the agency's payment plus any allowed deductible, coinsurance or copayment as payment in full for a covered service, and that inability to pay does not eliminate the beneficiary's cost-sharing liability.. While you participate, that leaves no gap between the state's rate and your cash price to bill a Medicaid patient for. The rule's one carve-out is refusing further services over unpaid required cost sharing.

Even the carve-out is narrower than it sounds. Inability to pay does not eliminate the individual's liability for cost-sharing charges 6Ref 6Centers for Medicare & Medicaid Services (2013).§ 447.15 Acceptance of State payment as payment in full..Supports that a Medicaid-participating provider must accept the agency's payment plus any allowed deductible, coinsurance or copayment as payment in full for a covered service, and that inability to pay does not eliminate the beneficiary's cost-sharing liability., so the amount stays owed without ever becoming billable above the Medicaid rate. Whether a provider who is not enrolled in Medicaid may charge a Medicaid-eligible patient cash for the same service is a separate question, set state by state. Put it to your state Medicaid agency in writing before answering it from a national article, this one included.

Medicare runs on its own track. Charging a beneficiary your cash price for a service the program would otherwise cover, with no Medicare claim behind the visit, runs through a written contract in which the beneficiary agrees not to submit, and not to ask the physician to submit, a Medicare claim for the service 7Ref 7Noridian Healthcare Solutions (CMS Medicare Administrative Contractor, Jurisdiction E Part B) (2026).Private Contracts with Medicare Beneficiaries - JE Part B.Supports that privately contracting with a Medicare beneficiary is a distinct, disclosed act requiring the beneficiary to agree not to submit, and not to ask the physician to submit, a Medicare claim for the contracted service.. A cash-price page on your website does not accomplish that. Neither does a membership agreement that never mentions Medicare, and the opt-out mechanics that make such a contract available are their own subject.

Sizing the cash side against the anchor

The cash side has to replace every dollar the dropped contracts were producing, at a price patients pay out of the same money they are already spending on deductibles. Work it as arithmetic first: the collections you are giving up, divided by the cash price you can hold, gives the number of paid visits a month the new side owes you.

Some of that can be a membership rather than a per-visit fee. That design is two tiers, one calendar, with limits of its own on what a fee may cover and who may be offered it, so settle those before anything is cancelled.

If any of the cash side runs over video, settle the licensure question first. It is the rule under everything in telehealth, and it decides which patients you may see before it decides what they pay.

One anchor also concentrates risk: a single amendment letter, one fee schedule update, or one network exit moves the whole insured half of the practice at once.

When to revisit the choice

Put a date on it, and name the events that move the date forward. An annual review against the same five columns is enough in a stable year. Four events should trigger an earlier one: an amendment letter from the anchor payer, a fee schedule update that moves your top codes, a shift in the plan types your patients carry, and a cash side that has grown past the anchor's contribution.

The KFF indicators run through 2024 3Ref 3KFF (2024).Market Share and Enrollment of Largest Three Insurers - Individual Market.Supports that a free, methodology-documented state-by-state indicator reports the enrollment and market share of the three largest insurers in each state's ACA individual market from 2013 through 2024, built from insurers' own MLR regulatory filings, as one input to an anchor decision. 4Ref 4KFF (2024).Market Share and Enrollment of Largest Three Insurers - Small Group Market.Supports the small-group-market counterpart of the same indicator series and its life-year enrollment measure (member months divided by twelve), as the equivalent lookup for a practice whose patients carry small-employer coverage., so a year-over-year look at your state costs a few minutes. Your own five columns cost longer and matter more, because a statewide share says nothing about whether those members are on your schedule.

Keep the anchor contract's termination clause somewhere you can find it. Whatever you decide this year is reversible only on the notice period that document sets, which is a number worth knowing before the next review.