"We do offer contract payments for people who are self-pay," she says, adding that because they're in a smaller community, following up with patients for payment due isn't as difficult as it might be in an urban setting.

And accepting insurance plans — any insurance plan — means physicians have to hire staff to manage billing. Haugen says that of the 12 employees on Harvey Clinic's roster, four of them deal with some aspect of billing and payments.

Joe Welfeld, president of consulting firm The Welfeld Group, says most physicians expect for exchange plan rates to be higher than those offered by Medicaid but lower than those paid by commercial plans.

"When you combine that with the high deductibles, not only does the physician get a lower reimbursement, but they also have the problem of collections," he explains. "People are really looking at the cost of the premiums, so they could walk in to see a provider and have this huge payment that has to kick in before they're even eligible for any of the benefits – particularly if they're going to a specialist or a hospital."

Dr. Stuart Gitlow has been practicing medicine for 21 years and has never accepted insurance contracts.

"One of the difficulties is that you don't typically get the reimbursement rates prior to signing the contract," he says. "For some reason, with medical insurance, they're not agreeing to anything except to have me on their panel, and I'm agreeing to be on their panel. And as an aside, they're agreeing to pay me based on their pay rate. And the first time I find out what they're going to pay me is after I've agreed to be on their panel."

And Gitlow agrees there's an "inordinate amount of paperwork and processing" that goes into collecting payment from carriers.

"If I had 40 patients I saw in a day, I'd have to hire somebody else, because I'd have 40 bills," he explains. "And now my costs are going to go up, because not only would I have to have this person properly trained, but if that employee makes a mistake and the insurance company says I've overbilled and this is fraud, I'm responsible even though my staff member made the mistake. And I'm not willing to take that risk."

There are other administrative burdens, too, including hiring coding personnel to ensure any codes submitted to carriers are accurate, and some payers are moving to pay-for-performance instead of fee-for-service models of payment, which means doctors have to provide information about the quality of care they're providing. That task is impossible without an electronic medical record system, the cheapest of which is thousands of dollars' worth of software.

"I sit in my office, and I use a piece of paper and a pen, and that's free," Gitlow says. "I can afford to see a patient for $50 or $60; very few patients can't afford that, and when those few patients come in and can't, I can see them for less and it's not an issue. The point where it becomes an issue is if you have cancer and you need an extremely expensive medication or an extremely expensive procedure. But that's what insurance should be for, is those rare cases where suddenly you're going to be confronted with some enormous amount."

Dr. Robert Haar, an orthopedic surgeon at Regency Healthcare, is a specialist who doesn't accept insurance at his practice; he lists the price of procedures on his website, allowing patients and employers a transparent view inside his operation.

"I think this particular model is going to be very palatable and attractive to small-to-moderate-sized, self-funded companies that choose not to buy insurance because it's too costly," he notes.

"They will choose instead to contract with providers and facilities like mine because they only pay a la carte, so to speak, when their employees really need health care. And the experience in terms of cost savings is growing to suggest that this form of obtaining and providing health care is much more cost-effective than the insurance-based model — because you're cutting out the insurance companies, the middlemen," Haar says.