Concierge Medicine

[Law2Doc]

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Must vary based ondoc and location. All the concierge docs I've seen are the annual retainer on top of insurance/cash for services...

just FYI, a concierge doc (or any doc really) cannot charge money on top of insurance legally. So it's a cash only business model. Which is why the market is so limited --you are asking folks to pay in cash for something they likely already have insurance coverage for through their work.

 

[alwaysaangel]

just FYI, a concierge doc (or any doc really) cannot charge money on top of insurance legally. So it's a cash only business model. Which is why the market is so limited --you are asking folks to pay in cash for something they likely already have insurance coverage for through their work.

There must be some work around for this rule because I have definitely seen concierge docs charge their annual fee plus bill insurance.

 

[Law2Doc]

There must be some work around for this rule because I have definitely seen concierge docs charge their annual fee plus bill insurance.

You aren't allowed to do this. I hope they like wearing orange.

This is the whole catch with concierge medicine, and why so few people are doing it-- you have to forego insurance and find cash only customers. Which means the market gets saturated very fast because so few people are going to pay cash for something when they already have insurance coverage through work. If you know concierge guys who are taking cash on top of insurance, they are getting piggy and breaking the rules. It's a form of insurance fraud. Stay far away from such people and don't use them as role models.

 

[alwaysaangel]

You aren't allowed to do this. I hope they like wearing orange.

*shrug* these were not docs who were charging a fortune for their retainer and theyre not stupid. I seriously doubt they were doing something illegal.

If its illegal to charge money on top of insurance then im sure there is a way around that (eg the patients pay $500 for the right to be seen and one comprehensive visit per year and then the doc bills the insurance for all other visits/labs/services). One even had patients on medicare which he billed. Seems unlikely that what theyre doing is blatantly illegal.

Also while im sure you know what youre talking about and such a law exists it doesnt make much sense to me even outside of concierge medicine. Docs/hospitals are always billing patients for the difference between actual cost and what insurance pays. That is charging money on top of insurance...

 

[Law2Doc]

*shrug* ... One even had patients on medicare which he billed. Seems unlikely that what theyre doing is blatantly illegal...

The guy billing Medicare patients for money is blatantly breaking several laws. I don't know what else to tell you. This is the reason so few people go into concierge medicine -- you have to forego all those insurance payor patients.

Do a google search on "balance billing". There's a good Bloomberg Business Week article on the abuse. At this point, most jurisdictions have disallowed the practice, but there are still many who still send the bills, preying on the ignorant. And the practice is illegal under Medicare.

 

[tigress]

It's not illegal to charge an annual fee just for the privilege of seeing the doctor, and then bill insurance for visits. It all depends on how they advertise the annual fee. It's illegal to bill for services that are also billed to insurance. That's not the same thing as charging for something that is not billable to insurance, namely the privilege of belonging to that concierge practice. This is how all of the concierge practices I have known have run.

 

[Law2Doc]

It's not illegal to charge an annual fee just for the privilege of seeing the doctor, and then bill insurance for visits. It all depends on how they advertise the annual fee. It's illegal to bill for services that are also billed to insurance. That's not the same thing as charging for something that is not billable to insurance, namely the privilege of belonging to that concierge practice. This is how all of the concierge practices I have known have run.

That's a form over substance argument, and these are always losers in court. The smart concierge players don't bill insurance companies, period. Not ever. You simply tell your patients that they have to forego their insurance if you want to use them. There isnt a legal way around this in most jurisdictions, and never with medicare or medicaid. The guys that try to play fast and loose with the insurance laws, taking both cash and insurance, are just waiting to get caught, I'm afraid. Again, this limit on customers is the big reason everyone doesn't do a concierge business -- the pool of potential customers is simply very small.

 

[boggvir]

As a patient I would never ever do this but hey if you can convince enough people to pay you for primary care over and above their insurance - go for it.

 

[JaggerPlate]

just FYI, a concierge doc (or any doc really) cannot charge money on top of insurance legally.

Yup.

 

[drturkleton]

That's a form over substance argument, and these are always losers in court. The smart concierge players don't bill insurance companies, period. Not ever. You simply tell your patients that they have to forego their insurance if you want to use them. There isnt a legal way around this in most jurisdictions, and never with medicare or medicaid. The guys that try to play fast and loose with the insurance laws, taking both cash and insurance, are just waiting to get caught, I'm afraid. Again, this limit on customers is the big reason everyone doesn't do a concierge business -- the pool of potential customers is simply very small.

Are you sure? Take a look at MDVIP, a larger player. My understanding is that a bunch of groups a) accept insurance and medicare and b) charge a retainer for the services they provide that, in theory, are not covered by insurance. Bear with me, since I have no legal background (although I do have a business background). But it seems to me that your argument applies to something like the following: a patient comes in for a blood test, the practice bills the patient for the blood test, and bills the patient's insurance for the blood test. This obviously sounds fraudulent.

On the other hand, I can't see how your argument applies to this case: a patient comes in for a blood test, and the practice bills the patient's insurance for the blood test. The practice then bills the patient a fixed annual retainer that specifically states that this fee is unrelated to the blood test. The same patient might get ten blood tests, his insurance then billed for ten blood tests, but the retainer would not change. I believe this is how the majority of concierge practices operate.

Now what if concierge practices used a business model that billed the patient for hours of work plus retainer, and then billed insurance for the procedure? I think it would be easier to make a legal argument against this model, but even still, I'm not sure if it's illegal. On the other hand, since retainer plus insurance and retainer plus cash-only are the dominant models out there, I don't think many patients would agree to retainer plus billable hours plus insurance.

But like I said, take a look at MDVIP - it's a big network with serious financial backers. Do you know of any specific rulings that say such a model is illegal? I'm not asking rhetorically, I just haven't looked into it myself very much. And again, like I said, concierge medicine isn't something I'd be able to do myself, but I'm just curious about the implications surrounding the model.

 

[tigress]

That's a form over substance argument, and these are always losers in court. The smart concierge players don't bill insurance companies, period. Not ever. You simply tell your patients that they have to forego their insurance if you want to use them. There isnt a legal way around this in most jurisdictions, and never with medicare or medicaid. The guys that try to play fast and loose with the insurance laws, taking both cash and insurance, are just waiting to get caught, I'm afraid. Again, this limit on customers is the big reason everyone doesn't do a concierge business -- the pool of potential customers is simply very small.

I'm also curious as to whether you know of any lawsuits over this. I only have an informal legal background (I did paralegal-type work for my mother for years), but out of curiosity I also asked a few of the lawyers I know (including my father who spends most of his time defending medical malpractice and is fairly knowledgeable on this), and they all agreed that the arrangement I described would be considered completely legal, because in no way is insurance being billed for something the patient is also paying for. The retainer fee to be considered part of the practice is exactly that, and it's not ambiguous. I'm not meaning to simply argue that you are wrong, just to say that my understanding is different, and mostly what I am finding backs up my understanding.

I do know that of 4 concierge practices I knew in Philadelphia and the 1 I know here in South Carolina, every single one operated under this arrangement--an annual fee plus billing insurance for visits. The one concierge doctor I knew best in Philadelphia (she had been my doctor prior to opening her concierge practice) was pretty careful legally, since she actually opened her practice in order to provide the kind of maternity care she wanted (basically midwife-style care) and was mindful of legal pitfalls. (In talking to a good friend, I can add another data point from Boston: her OB/midwife practice also operated under this model.)

(I want to reiterate that I'm not in this to prove you wrong, in any way. I simply want to understand the legality of this, since in my experience (and it seems most people's experience), this is how the vast majority of concierge practices are run. If, as you say, the are all "just waiting to get caught", why haven't there been more (or any?) lawsuits?

 

[cpants]

I too know of multiple practices following this model, and indeed I would think that most are set up this way. For a 1000 bucks a year you would go broke providing unlimited primary care. You bill patients for access and then bill insurance for visits. I am pretty sure it is legal as long as you set it up the right way. The patient is paying for your cell phone number and email address, certain other perks. Insurance pays for the visits. Certainly it would be illegal if they said all visits were included in the retainer fee, but that's not how they set it up.

 

[alwaysaangel]

It's legal. Here is an article for anyone interested: http://www.conciergemedicinetoday.com/legal.html

But it very clear in the first paragraph:

The largest segment of the concierge medicine industry is now almost ten years old. The legal foundation on which it is based was laid in 2002, when Tommy Thompson, the then-secretary of Health and Human Services, formally concluded that physicians who participate in Medicare could nonetheless charge patients a special fee in exchange for services that are not covered by Medicare, even when the fee amounts to a precondition to providing Medicare-covered services to those patients.

I didn't think there was anyway so many well respected, intelligent docs weredoing something blatantly illegal.

 

[Law2Doc]

It's legal. Here is an article for anyone interested: http://www.conciergemedicinetoday.com/legal.html

But it very clear in the first paragraph:



I didn't think there was anyway so many well respected, intelligent docs weredoing something blatantly illegal.

Do a google search of "balance billing" and you will find more recent resources which explain that the 2002 ruling you cited is no longer the law... You can't balance bill over and above Medicare. And in many jurisdictions under state law you can't balance bill on private insurance either.

 

[alwaysaangel]

Do a google search of "balance billing" and you will find more recent resources which explain that the 2002 ruling you cited is no longer the law... You can't balance bill over and above Medicare. And in many jurisdictions under state law you can't balance bill on private insurance either.

Did you even click the link before knee jerk arguing against it?

The article is not AT ALL about balance billing. It's about billing for services not covered by Medicare.

It's an April 2011 article about the changes in the law that will affect the legality of concierge medicine and the adjustments needed to stay legal. So it's also not out of date. The article even admits that it's legally tenuous and cites a case where a doc got sued. But it's very clear and well cited on how to stay within the law.

 

[Law2Doc]

Did you even click the link before knee jerk arguing against it?

The article is not AT ALL about balance billing. It's about billing for services not covered by Medicare.

It's an April 2011 article about the changes in the law that will affect the legality of concierge medicine and the adjustments needed to stay legal. So it's also not out of date. The article even admits that it's legally tenuous and cites a case where a doc got sued. But it's very clear and well cited on how to stay within the law.

Sorry. I wasn't able to open the link for firewall reasons, so I have no idea what it says beyond the quote you posted. I responded to the quote you highlighted that discussed Thomson's 2002 opinion that Medicare doesn't prohibit balance billing -- in fact it now does. So if that's the foundation of concierge medicine, then it's founded on a law that's no longer valid. Bottom line, you cannot bill on top of medicare today. In many jurisdictions (maybe most) you cannot bill on top of private insurance. This leaves concierge medicine as a cash only business model in lieu of insurance in most jurisdictions.

 

[alwaysaangel]

Another interesting page on the topic: http://www.camlawblog.com/articles/health-trends/concierge-medicine-raises-legal-issues/

It apparently has to be done very carefully but is in now way blatantly illegal.

 

[alwaysaangel]

I responded to the quote you highlighted that discussed Thomson's 2002 opinion that Medicare doesn't prohibit balance billing -- in fact it now does. So if that's the foundation of concierge medicine, then it's founded on a law that's no longer valid. Bottom line, you cannot bill on top of medicare today. In many jurisdictions (maybe most) you cannot bill on top of private insurance. This leaves concierge medicine as a cash only business model in lieu of insurance in most jurisdictions.

Well the quote I listed isnt even talking about balanced billing. Again, it's talking about services not covered. So they may have since made balanced billing illegal but that is a separate entity entirely. (even if that was part of the original ruling, unless the ENTIRE ruling has been overturned)

Everything I'm reading says if you do it right and make a clear contract that makes your retainer for "non-covered services" (like house calls, 24 hr access, same day visits, etc) then you are within the law to charge an annual fee and then bill covered services (visits, labs, etc) to Medicare or insurance.

 

[Law2Doc]

Ok so I just found way around the firewall.

I think the article is right in saying that the 2010 law has made it far more difficult to run a concierge business. However I think it is a bit disingenuous in suggesting that the loopholes were actually "legal" even before this act. It sort of shrugs off an enormous settlement that a doctor had to make in 2007 as well as pretty explicit language in the current act explicitly suggestion that concierge services are problematic.

I know the score. As a lawyer you take positions right up to the line where you can make an argument of legality with a straight face. I'm sure this firm has a number of concierge clients they cater to, and having them push the envelope makes for plenty of legal fees. But as always, there's a difference in what investment you would recommend to a stranger versus a close family member. You don't want to be the next 2007 test case where you lose your nest egg because you ran fast and loose with the rules.

 

[Law2Doc]

Another interesting page on the topic: http://www.camlawblog.com/articles/health-trends/concierge-medicine-raises-legal-issues/

It apparently has to be done very carefully but is in now way blatantly illegal.

Lol. He didn't actually say it was legal. He actually said it was fraught with problems and that if you are going to do this business you are going to need help of experienced lawyers (ie him).

This is the kind of thing you should really regard as too close to the line. I've seen and taken positions that were very fine loopholes in my day, and in more than a few the government didnt share the lawyers' view, and it cost the client dearly. You don't pick a career that only exists because some lawyer thinks that it's allowed through a strained reading of the rules.

 

[alwaysaangel]

Lol. He didn't actually say it was legal. He actually said it was fraught with problems and that if you are going to do this business you are going to need help of experienced lawyers (ie him).

This is the kind of thing you should really regard as too close to the line. I've seen and taken positions that were very fine loopholes in my day, and in more than a few the government didnt share the lawyers' view, and it cost the client dearly. You don't pick a career that only exists because some lawyer thinks that it's allowed through a strained reading of the rules.

That's fair. And it's not something I'm planning on doing. I matched into EM. Can't really imagine a concierge market for that.

I was mostly trying to figure out why so many docs were doing it.

So it's definitely a grey area and could end very soon. But it's done quite a bit from what I've seen (I've never met a cash only concierge doc).

 

[Law2Doc]

So it's definitely a grey area and could end very soon. But it's done quite a bit from what I've seen (I've never met a cash only concierge doc).

I would argue the area isn't very grey. as far as people doing things "quite a bit" despite questionable legality, I refer you to the tax shelter industry a few decades back, where many thousands of otherwise respectable investors tried to play fast and loose with the US tax laws because lawyers similarly told them there were loopholes they could navigate.

I've met cash only concierge folks, and their businesses only work because they have no competition, open themselves up to providing service 24/7 for a select group of handpicked healthy rich patients and stay far away from the insurance industry.