Concierge, Direct Pay, or Hybrid: Is One Right for You?

Leigh Page


April 06, 2016

In This Article

Potential Pitfalls of Concierge

Concierge practices' continued relationship with payers can backfire. When an insurer learns that a practice is "going concierge," it may drop it from its network, according to both Greenspan and Marquis. Different reasons have been given as to why some insurers don't like concierge practices. They might think the extra attention that concierge doctors give patients will mean ordering more services. Or they might be concerned that when practices reduce panel size, it's harder to find enough physicians to cover all of their members.

Marquis says that more insurers seem to be dropping membership practices from their networks. "They don't need a reason to drop you, and there are no appeals," he says. Leaving the insurance network isn't fatal, though. You can still bill for out-of-network care. But patients will have higher payments, and this may cause some of them not to renew their membership, he says.

Marquis says that a much more dangerous issue for concierge practices is Medicare compliance. When practices with Medicare beneficiaries list their extra services for patients, they have to be careful not to include services that Medicare already covers because then they're double billing, which is illegal in Medicare. In addition to paying steep fines and being kicked out of Medicare, "you can go to jail for so-called false claims," Marquis says.

Only in a couple of instances has the Office of the Inspector General (OIG) for the Department of Health and Human Services gone after concierge practices on this issue, Marquis says. In a 2007 case,[2] a North Carolina physician agreed to pay $106,600 to resolve the OIG's allegations. "What is disturbing about this case is that, from all appearances, this concierge physician wasn't doing anything different from what other concierge physicians do," Marquis says. "His membership agreement covered the usual concierge offerings."

Today, the most obvious target for OIG investigation is the concierge practice's annual physical. This offering is similar to the Medicare annual wellness visits, which Medicare started reimbursing in January 2011. Some consultants argue that because the concierge physical involves a much longer list of services than what Medicare covers, there is not enough of an overlap to be a concern, but Marquis disagrees. He notes that when the OIG's office charged a Minnesota concierge physician with double-billing,[2] it stated that any kind of overlap would be a problem.

Telehealth might be the next battleground for double-billing. The Centers for Medicare & Medicaid Services (CMS) has been expanding coverage of telehealth services, and this might conflict with concierge practices' coverage of phone calls and emails. But Marquis is taking a wait-and-see attitude. "When Medicare starts to cover email advice to patients, then the email should not be included in the offered services," he says.


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