More physicians are turning to concierge and hybrid concierge models to shrink their panels and steady their finances, but the move carries legal exposure that’s easy to miss until it becomes a problem. Health care attorney Ericka Adler, J.D., breaks down the contract and Medicare traps that can turn a panel-shrinking strategy into a legal problem.
According to the report, a membership fee has to be tied to a service insurance doesn’t already cover, and what counts as “not covered” changes year to year. This is particularly important in a hybrid model, where the membership fee must cover something insurance doesn’t.
Choosing the right entity for a concierge practice is no different than for any medical practice, and state law drives the choice. Ericka Adler explains that in a hybrid model, the membership fee has to cover something insurance doesn’t, and what counts as “not covered” changes year to year.
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Proper notice, terminating contracts, and why you can’t force insured patients to pay a concierge fee to stay are also important considerations. Adler notes that annual physicals are now covered, and 24/7 access may already be required, and old membership documents can leave you charging for things you no longer can.
The patient contract must spell out the fee, what it covers, proration, and what happens when a patient dies, moves, or leaves. Adler emphasizes the importance of informed consent, HIPAA, financial forms, and good faith estimates, all of which still apply, no matter the specialty.
Risks unique to concierge practices, such as a cash-based practice’s exposure differing from a hybrid model that still bills insurance, must also be considered. Adler warns that “24/7 access” can’t be the basis of a hybrid membership fee when most plans already require equal treatment.
Planning is essential.
Patients, market research, and planning are essential to making the transition to a concierge or hybrid model work. Giving patients runway, avoiding abandonment, and making sure your community can actually afford the fee are critical considerations. Adler notes that the financial, marketing, and legal steps must be taken in order, and that private equity money is moving into concierge care.
The transition to a concierge or hybrid model requires careful planning and execution. By understanding the legal considerations, Medicare and patient contracts, and planning and transitioning strategies, physicians can avoid common pitfalls and create a successful and sustainable practice.
Ultimately, the key to a successful transition is to approach it with a clear understanding of the legal and financial implications, as well as a deep understanding of the needs and expectations of your patients. By doing so, physicians can create a practice that is both profitable and sustainable, while also providing high-quality care to their patients.
