LEGAL 2.0: ACA and Concierge Medicine – What to Expect, Thomas Shapira, Esq.

By Thomas Shapira, Esq.
Harrison & Held LLP, Chicago, IL

concierge medicine guideOCTOBER 30, 2013 – The recent Affordable Care Act (“ACA”) implementation provides an opportunity for concierge physicians to examine their practice models to ensure continued legal compliance. Most ACA provisions do not directly impact concierge physicians, nor does the ACA specifically address the concierge practice model. However, as more individuals obtain health insurance (at least that was the point), there will be a greater demand for internists and other primary care physicians. For concierge practices, it is unlikely that these newly-insured patients will represent a demographic that seeks membership in a concierge practice. For non-concierge physicians, the increase in patients, combined with additional administrative burdens and lower reimbursement, may spur these physicians to consider the concierge model.

A vital legal issue for concierge medicine, exacerbated by the expansion of covered services under the ACA, continues to be the potential for “double billing” for services. A medical service covered by a healthcare payor, whether Medicare or commercial payors (assuming the concierge physician remains an in-network provider), cannot also be paid by the patient under the annual fee. Therefore, a concierge physician must be familiar with those services which are “covered” by the patient’s payor. The ACA expanded the scope of Medicare-covered services that may include certain components of an Annual Wellness Exam. Prior to ACA, Medicare only covered a “Welcome to Medicare” exam in a patient’s first year of eligibility. The covered components of the exam should be billed to Medicare. However, the practice description can specify that the annual fee only covers those exam components that are not covered by Medicare. If the annual fee includes exam components that are covered by Medicare, and the practice bills Medicare for those components, then the practice should refund this reimbursed portion to their patients. In this way, the records accurately reflect that the practice did not receive an annual fee as well as Medicare reimbursement for what may be the same service.

As healthcare regulation evolves, additional medical services likely will be covered by Medicare and commercial payors. To avoid annual updates to the practice model to carve out these newly-covered items from the annual fee, concierge practices should consider excluding medical services from the annual fee, potentially even eliminating the annual wellness exam as an included benefit. Offering members a greater array of non-medical services and amenities is another viable solution.  More concierge practices are adding amenities such as house calls (same fee as an office visit), negotiated discounts with ancillary health providers (dieticians, nutritionists, physical trainers, massage therapists), and non-traditional healthcare options. If the annual fee does not include medical services, it will be easier for the practice to remain in legal compliance.

specialdocs_testConcierge medical practices have always represented the forefront of health care delivery innovation and will need to keep pace with the changing environment.

The content of this article: (i) is for informational purposes only and does not constitute legal advice, and (ii) is not intended to create, and your receipt and/or use of such content does not create, a lawyer-client relationship. You should not rely on any such content without first consulting a licensed attorney familiar with your particular facts and legal issues.

Source: SpecialDocs; Thomas Shapira, Esq. Harrison & Held LLP, Chicago, IL

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