Proper billing under payer agreements: A concierge practice may mean that a physician can eliminate, or at least reduce, the number of insurance companies or payers they have to work with. This can cut administrative and billing costs. However, it is essential to design the practice in a way that complies with payer rules and regulations, especially when a practice bills state and federal programs, such as Medicaid and Medicare. Medicare has strict rules outlining when a practice can charge a patient directly for services usually covered by Medicare. For example, if a physician accepts any payments from Medicare, the practice will not be able to bill patients directly for any services covered under Medicare. If the practice wants to bill any patients directly, it will need to opt out of Medicare completely. With respect to private payers, physicians need to analyze the contract. Some commercial payers may prohibit concierge practices or billing arrangements outright in their agreements.
State laws: States may regulate concierge arrangements through a variety of laws. Some states have considered some concierge practices to be engaging in the unauthorized business of insurance, which subjects the practice to that state’s insurance laws. Other states have passed legislation surrounding balance-billing requirements and prohibit charging the patient anything more than a co-pay or deductible. Anti-discrimination laws in some states may also apply to certain practices that require patients to pay a retainer to remain a patient of the practice.
Ethical considerations: The American Medical Association has published written guidance detailing the ethical considerations surrounding concierge medicine. This guidance stresses physicians cannot claim that concierge services are better than traditional services. Additionally, patients must participate in a voluntary manner, and if patients do not want to be part of the practice model, their physician must help facilitate a transfer of care to avoid abandonment issues. Further, services rendered under a concierge model must be medically necessary.
A concierge practice may mean that a physician can eliminate, or at least reduce, the number of insurance companies or payers the physician has to work with.
Bottom Line
When designed correctly, concierge medicine can prove lucrative for some physicians and practices. However, as noted, several different types of concierge practice models exist, each of which can present a number of complex issues. Therefore, physicians must design these practice types in an ethical and thoughtful way to keep payers and patients happy. Due to the various models, the complexities of the concept and the legal issues that may arise, consulting with an experienced attorney is recommended before physicians establish any type of concierge medicine practice.
