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Concierge Medicine Practices: Commercial Payor Compliance Risks

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This is our third blog post on concierge medicine practices this month due to an increase in interest by our business and healthcare law firm’s clients.  Previous blog posts provided an overview of what concierge medicine is and an overview of compliance risks under Medicare.  This post continues the topic by discussing how commercial payors view concierge medicine practices.   If you have questions regarding this blog post or starting a concierge practice, you may contact us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email, info@hamillittle.com. You may also learn more about our law firm by visiting www.hamillittle.com.

As stated in our previous post, understanding the compliance risks associated with concierge medicine practices requires understanding a fairly easy and, perhaps, obvious concept: Providers cannot bill patients for services paid for by their insurance; a practice referred to as “double billing.”  The general rule is the same for Medicare and commercial payors.  Generally, third party payor agreements will prevent the enrolled provider from charging a patient directly for services covered by insurance (apart from copayments and deductibles).  What is more complicated with commercial payors is that each one may have a different stance on concierge practices.  As an example, AETNA has a public policy on concierge medicine that is available on pages 20-23 of its provider manual.  In an important part, the policy states:

 

  • [W]e discourage the provision of concierge care services by participating providers. You may charge concierge fees to our members under the limited circumstances described in the next paragraph. However, participating providers may not charge concierge fees for a plan member to access covered services and/or standard administrative services. In other words, you can’t charge a member an annual fee to join or remain in your practice. You also can’t charge a separate concierge fee for any standard administrative services, such as prescription orders or renewals, referrals, medical record maintenance, or returning phone calls.

  • While discouraged, you may charge reasonable concierge fees for a member to access other amenities, such as a fee in return for preference in scheduling appointments.

  • If your practice is going to charge concierge fees, you must inform your Aetna® Network Manager in advance. We reserve the right to indicate whether a provider practices concierge care in our provider search tool and other materials.

  • Concierge fees are prohibited for Aetna Medicare Advantage members.

 

For each commercial payor your practice will enroll with, it is important to evaluate your participating provider contract as well as policies otherwise maintained by that provider.  This can be a large undertaking, but an important one to ensure your practice’s ability to bill and collect from each payor is not interrupted.

Our firm works with many providers to create forms and other policies to lawfully create concierge medicine practices considering each practices unique needs.  If you have questions regarding this blog post or wish to discuss the process opening a concierge practice, you may contact us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email, info@hamillittle.com. You may also learn more about our law firm by visiting www.hamillittle.com.

*Disclaimer: Thoughts shared here do not constitute legal advice.