Is Concierge Medicine Legal?

Is Concierge Medicine Legal?

Corey Rose

concierge medicine practice arriving at home

Concierge medicine, also known as boutique medicine and retainer medicine, is where patients pay their physician or practice a membership or retainer fee. Concierge patients pay this upfront fee in return for direct access to their concierge doctor and a personalized care package. Care agreements are made between patients and concierge physicians that determine the level of care that will be included in membership fees and the services that will incur additional medical bills.

While concierge medicine caters primarily to those who can afford care of this kind, concierge medical practices are on the rise and annual fees are becoming more affordable. And while there are some legal issues to consider there is no reason why concierge models of care cannot be legally, ethically and medically sound.

What is Concierge Medicine?

Concierge medicine involves patients paying an annual or monthly fee for their medical care, in much the same way as you might pay a law firm a retainer so you can always see your lawyer, you can pay your care provider a fee so that you can always see your doctor. Concierge medicine can provide a customized health plan that deals with both physical and mental health with a greater level of patient engagement. Concierge doctors can provide annual physicals as well as on-demand care usually with shorter wait times.

Concierge medicine has seen a big rise in popularity since the enactment of the affordable care act in 2010. The care act was designed to extend health care to millions of Americans that currently didn’t have access to medical care by expanding access to health insurance.

One of the impacts of more people having access to primary care is that it becomes more difficult to get an appointment at your primary care practice or see your usual primary care physician. With more pressure on appointments, a physician practice wishing to maintain or improve patient experiences may look to concierge medicine as a way of maintaining care delivery and reducing the number of patients cared for, more in line with older care models where patients would have an ongoing relationship with their family physician.

Does Insurance Cover Concierge Medicine?

One of the potential issues related to concierge medicine is whether or not your insurance plan will cover your medical costs. One of the reasons that concierge medical care is on the rise is that it is easier to see a doctor in concierge practices than it is to get an appointment with traditional primary care physicians. One of the reasons for this is that you have already paid upfront rather than having to wait for your insurance company to authorize payment.

Generally medical insurance will not cover your monthly fee so this will need to be paid directly, but depending on your care plan most concierge doctors and practices will accept and bill Medicare or private insurance for additional treatment and services.

However it is worth being aware that doctors are able to opt-out of Medicare. This is one of the legal issues to consider related to concierge medicine as opting out of Medicare coverage can make things easier for practice managers.

The US Department of Health and Human Services (HSS) has determined that concierge medicine is legal provided that agreements do not violate Medicare requirements. This means if Medicare patients pay a fee this must not include a charge for any direct primary care services that Medicare covers. This can cause legal issues for a medical practice as it can be hard to know where to draw the line, and mean it is important that a Medicare patient is given a tailored patient contract that does not include any services that Medicare covers.

Is Concierge Medicine Ethical?

Although there are a number of issues to consider with concierge medicine there is no reason why this style of medical care should not be ethical.

One of the issues with concierge medicine is the question of whether or not this style of clinical practice is creating a tiered health system. Ethics come into play if abandonment were to occur due to a patient not being able to pay. However, this type of managed care also gives patients more choice and has a higher focus on preventative medicine. This type of care practice provides more managed care and can reduce pressure on hospitals and emergency rooms thus being of benefit to the hospital and health system as whole as well as individuals.

Why are Doctors Going to Concierge Medicine?

With changes in health laws and increased pressure of primary care physicians more and more seem to be moving towards offering concierge care whereby patients pay a retainer fee in advance for their care.

New business models including concierge care can improve the patient experience as physicians are able to spend more time with fewer patients. While patients payment plans increase revenue for physicians, physician assistants and medical centers allowing them to provide a better quality of service.

Switching to concierge medicine gives doctors more time with patients and allows them to provide a more bespoke clinical practice, they can offer house calls to patients that require them, provide a regular physical exam to help prevent illness and are able to reduce their dealings with insurance companies and the administration costs that this entails.

Is a Concierge Doctor Worth the Cost?

With prices becoming more and more affordable more and more people are able to afford concierge medicine and all the benefits that come with it.

Knowing that you always have access to a doctor and that the cost of your day to day care is already covered can give great peace of mind. Not to mention the fact that regular physician visits will help to prevent many illnesses from occurring in the first place.

Working with a doctor to create a personalized and holistic treatment plan at TMS medical is the first step toward improving your mental and physical health and starting your journey to recovery.

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