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Most real practices are hybrids: in-network for some payers, cash for everything else, maybe a membership plan for the uninsured. Hybrids capture more revenue but inherit the compliance surface of every model they touch, plus a few seams unique to mixing them.

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The seams to watch

You can’t bill a patient cash for a covered service under a contract that forbids it. Participation agreements typically require you to bill the payer for covered services and limit what you can collect from members. Cash pricing applies to non-covered services, out-of-network patients, or patients who sign the payer’s version of an advance notice (Medicare’s ABN being the canonical one). Your cash price also talks to your fee schedule, payers may audit against “usual and customary,” and a cash price below a contracted rate invites repricing arguments. Membership plans for insured patients must be built from things insurance doesn’t cover, or they collide with both the payer contract and state prepaid-plan rules (see cash-pay model).

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Operationally

Run one ledger with clear revenue classes (insurance, patient responsibility, cash service, membership), settle card revenue and payer EFTs into identifiable accounts (account structure), and reconcile the two streams separately, insurance by ERA, cash by processor settlement report.