The Neurologist's Guide to Direct Care: Building a Practice Without Prior Authorizations

A direct-care neurology practice runs on a membership, not on insurance reimbursement — which means the prior authorization burden that consumes 13 hours of physician time per week in a conventional practice simply does not apply. The membership fee covers clinical access; diagnostic studies are ordered at negotiated cash prices; and the physician makes the call on what the patient needs without waiting for insurer approval.

Why are neurologists leaving insurance-based private practice?

Neurology carries one of the highest prior authorization burdens in medicine. MS biologics, anti-seizure medications, MRI studies, nerve conduction studies — nearly every high-cost intervention that defines neurological care requires prior approval before the patient can access it.

The AMA's 2024 survey found that the average physician completes 39 prior authorization requests per week, spending 13 hours on them. Eighty-nine percent report prior authorizations significantly contribute to burnout; 79 percent say they have led to treatment abandonment — patients who needed that medication or scan and did not get it because the friction was enough to stop the care.

For neurologists, the stakes are higher than average. Prior authorization delays in MS are associated with documented disease activity and relapses during approval waits. In epilepsy, delays in starting or adjusting anti-seizure therapy carry real seizure risk. That burden has accelerated the exit from independent practice: fewer than half of physicians were in private practice in 2024, down from 60% in 2012.

What does a direct-care neurology practice actually look like?

A direct-care neurology practice operates on a monthly membership that covers the physician relationship: visits, between-visit messaging, care coordination, prescription management, and referral generation. Diagnostic studies — MRI, labs, EMG and nerve conduction studies — are ordered separately at cash prices the practice negotiates directly with providers.

Panel sizes are small by design. A neurologist managing an active panel of MS, epilepsy, and headache patients typically sees 8 to 12 patients a day. That ratio makes 45- to 60-minute visits financially sustainable, and 60-minute visits are what complex neurological care requires.

The direct-care model fits neurology's patient profile well:

• Chronic disease management — MS, epilepsy, Parkinson's, and chronic migraine patients need quarterly-to-annual monitoring, medication adjustments, and access between visits. Memberships charge for the ongoing relationship, not the discrete encounter.
• Complex diagnostic evaluation — New-onset neurological symptoms require long initial visits: detailed history, neurological exam, ordering. A 60-minute new patient visit is difficult to reimburse under insurance; under a membership it is just a visit.
• Between-visit access — Patients need to report breakthrough seizures, new MS symptoms, or concerning cognitive changes without scheduling first. Direct access reduces the emergency visit that happens when a patient cannot reach a specialist quickly.

In SigmaMD, membership plans are configured in the Billing section — the practice sets the rate and cycle, enrollment generates the billing schedule, and charges process without manual invoicing. Psychiatrists building direct-care practices use the same structure: long-visit memberships on a recurring billing schedule.

How does lab and imaging ordering work without insurance?

In a direct-care neurology practice, diagnostic orders go through the practice's negotiated cash contracts — not through an insurer's formulary. In SigmaMD, neurologists order labs from the patient chart by clicking "Order labs," then selecting from configured providers. Practices connect with Labcorp through Healthcare Procurement Solutions — a no-cost group purchasing organization with pre-negotiated cash-pay rates — or with Quest Diagnostics with support from the SigmaMD customer success team. The diagnostic provider setup guide covers what SigmaMD needs to establish each interface and route results back to the chart.

For imaging, SigmaMD's imaging order screen lets the neurologist select the provider, set the billing type, and mark an order STAT when urgency requires it — the requisition PDF displays STAT prominently so the imaging center sees the priority. Step-by-step guides cover both lab ordering and imaging ordering in SigmaMD.

Practices can build custom lab panels in SigmaMD — a quarterly metabolic panel for patients on valproate, a thyroid and metabolic panel for a new intake, a demyelinating workup panel. The practice defines each panel once; reordering takes a few clicks rather than adding tests individually each time.

How does documentation work for long neurology visits?

A 45-minute neurology visit generates more documentation than a 10-minute primary care follow-up. In SigmaMD, neurologists build note templates and snippets tailored to their common visit types — an MS follow-up template that structures symptom inventory, medication review, and infusion tracking; a migraine template that prompts frequency and trigger logging; a seizure review template that captures last event, current medications, and adherence. These are templates the practice creates and refines; the structure is theirs to define.

Note templates and snippets work with SigmaMD Scribe, the AI documentation assistant that records ambient audio during the visit and generates a structured draft note. Recent improvements include better extraction of active problem lists, medication changes, and referral classification — Scribe now correctly distinguishes between ordering a study in-house and routing it as a specialist referral, which matters in neurology where MRI and EMG are performed outside the office.

When a study needs to go to a specialist facility, SigmaMD generates a referral PDF from the patient chart. Click "Referral" in the chart header, select what to include — problems, medications, allergies, imaging results, ICD-10 codes — add recipient details and a cover page with your signature, and send via the integrated fax service. The referral can attach signed clinical notes, prior lab results, and uploaded documents.

How does between-visit care work in a neurology membership?

The value of a neurology membership is ongoing access, not just scheduled visits. In SigmaMD, patients message the neurologist through the SigmaMD Patient Mobile App or web portal at patient.sigmamd.com. Messages are end-to-end encrypted and route to the clinician interface; if a message goes unanswered, the patient receives an SMS notification so urgent symptom reports do not sit unread.

A patient with epilepsy who has a breakthrough seizure needs to reach their physician, not a triage nurse. A patient with MS noticing new balance changes needs to report it in context — current medications, recent activity, whether there was a fever — not reconstruct the picture three weeks later at a scheduled appointment. SigmaMD's secure messaging keeps that communication inside the patient chart, attached to the record.

For symptoms that need visual assessment — a new tremor, a facial droop, or a balance change the patient wants to show rather than describe — SigmaMD's built-in telehealth lets the neurologist start a video visit from the patient chart. The patient joins via SMS link in their browser, no separate app required (telehealth guide). Patients can also self-schedule follow-up visits directly in the SigmaMD Patient App based on appointment types the practice configures.

FAQ

Can a neurologist practice direct care exclusively, or does it require a hybrid model?

Both work. Fully cash-pay neurology practices operate with no insurance billing — no claims, no in-network contracts, no prior authorizations. Hybrid models carry membership patients alongside insurance-billed patients, though the overhead of maintaining both reduces the efficiency gains on the direct-care side.

How does a direct-care neurologist handle expensive medications like MS biologics?

The membership covers the physician relationship; specialty medications are prescribed through the normal specialty pharmacy channel. Patients pay out of pocket, use manufacturer patient assistance programs — most MS biologic manufacturers have them — or run prescriptions through whatever insurance coverage they carry. The neurologist's decision is clinical, not contingent on insurer approval.

What conditions are the strongest fit for a direct-care neurology membership?

Migraine, epilepsy, MS, Parkinson's, peripheral neuropathy, and cognitive disorders are the most common panel compositions in direct-care neurology. The common thread is chronicity — conditions where monitoring and between-visit access determine outcomes more than any single encounter does.

Is there patient demand for direct-care neurology?

The average wait to see a neurologist runs nearly 50 days for commercially insured patients. Direct-care neurology members typically access their physician within days and have direct communication access between visits. That gap is the clearest evidence of demand.

What is the next step to set up a direct-care neurology practice?

SigmaMD is built for direct-care and specialty practices — membership billing, lab ordering with cash pricing, AI documentation, referral generation, and secure patient messaging are all part of the platform. Neurologists evaluating platforms can review the guide to choosing an EMR for direct care. Book a demo to see how SigmaMD handles a neurology workflow.