concierge medicine: key legal...

Presenting a live 90‐minute webinar with interactive Q&A

Concierge Medicine: Key Legal ConsiderationsBest Practices to Comply With Medicare Regulations, Insurance Laws and the Anti‐Kickback Statute

T d ’ f l f

1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific

WEDNESDAY, JUNE 22, 2011

Today’s faculty features:

Deborah C. Hiser, Partner, Brown McCarroll, Austin, Texas

Julie E. Kass, Principal, Ober|Kaler, Baltimore

Robert M. Portman, Principal, Powers Pyles Sutter & Verville, Washington, D.C.

Joshua M. Kaye, Partner, McDermott Will & Emery, Miami

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Concierge Practice Models gand Implications of PPACA

Deborah C. Hiser, PartnerBrown McCarroll LLP

512-703-5718 [email protected]

June 22, 2011

5

What is Concierge Practice?

• 2002 Secretary of HHS stated physicians2002 Secretary of HHS stated physicians participating in Medicare could charge patients a special fee to provide services p p pthat are not covered by Medicare

• Concierge physician practices have since g p y pprovided upgraded service for a fee:– 24/7 phone service– E-mail access and – No wait time for appointments

6

Concierge Practice Models

11 RetainerRetainer: patient pays retainer for: patient pays retainer for1.1. RetainerRetainer: patient pays retainer for : patient pays retainer for physician to cover all primary care needsphysician to cover all primary care needs

Retainer varies with level of service offeredRetainer varies with level of service offered–– Retainer varies with level of service offeredRetainer varies with level of service offered–– Physician may consider patient’s age and Physician may consider patient’s age and

health to determine retainerhealth to determine retainerhealth to determine retainer health to determine retainer –– Physicians using the retainer model cannot Physicians using the retainer model cannot

accept Medicareaccept Medicareaccept Medicareaccept Medicare

7


22 Fee For ServiceFee For Service: patient pays physician: patient pays physician2. 2. Fee For ServiceFee For Service: patient pays physician : patient pays physician as services are delivered as services are delivered

Model is more economical for patientsModel is more economical for patients–– Model is more economical for patients Model is more economical for patients because they only have to pay for the because they only have to pay for the services they use services they use yy

–– Issues arise if patient requests reimbursement Issues arise if patient requests reimbursement from Medicare or private insurers for a service from Medicare or private insurers for a service ppphysician billed for due to prohibition on physician billed for due to prohibition on balanced billingbalanced billing

8


3. 3. Fee For NonFee For Non--Covered Medical ServicesCovered Medical Services: : physician charges patients a fee for services that physician charges patients a fee for services that are beyond what insurance coversare beyond what insurance covers–– Patient’s insurer is charged for the basic servicesPatient’s insurer is charged for the basic servicesPatient s insurer is charged for the basic services Patient s insurer is charged for the basic services

provided. The patient pays out of pocket for “extra” provided. The patient pays out of pocket for “extra” services not covered by Medicare or private services not covered by Medicare or private insurance.insurance.

–– Must ensure that the service the patient is paying out Must ensure that the service the patient is paying out of pocket for is not too similar to a service covered by of pocket for is not too similar to a service covered by MedicareMedicare

•• Chare for “private reception area complete with amenities” is Chare for “private reception area complete with amenities” is similar to the “general office overheard” charge Medicare similar to the “general office overheard” charge Medicare already covers already covers

9

Medicare and Concierge Practice

• Concierge Physicians Accepting Medicare Assignment: Physician is able to bill directly to Medicare for “covered” services only

– Must differentiate between services that are and are not covered by Medicare. Cannot charge a retainer to provide patients with “covered” services

– Medicare will not reimburse for retainers because there is no way to differentiate between services that are and are not covered by Medicare

• Concierge Physicians Not Accepting Medicare Assignment: Patient pays physician for services, physician submits claim for patient and Medicare reimburses patient for 80% of fee schedule price for the “covered” service

– Physician may only charge patient 115% of the Medicare fee schedule price Medicare assess penalties if more than 115% of the Medicare fee schedule price is charged– Medicare assess penalties if more than 115% of the Medicare fee schedule price is charged

• Concierge Physicians Opting Out of Medicare:– Physician must “opt out” of Medicare

• Physician cannot select what patients he “opts out” for “Opting out” applies to all patients• Physician cannot select what patients he opts out for. Opting out applies to all patients. – Physicians using the retainer model must “opt out”– Often the safest route due to anti-kickback laws

• Medicare participating physicians may not provide a free service more than $10 to induce referrals. Physicians participating in Medicare must ensure that fair market value is charged f ll t i ff dfor all extra services offered

10

PPACA’s Effect on the Concierge PracticePractice

• PPACA created the “Annual Wellness Visit”

– Previously Medicare only paid for 1 wellness visit upon Medicare enrollment. Concierge physicians avoided double billing by not charging a special fee for the patient’s initial wellness visit.

– The services provided under Medicare’s “Annual Wellness Visit” and a concierge physician are very similar.

– Concierge physicians should consider whether to charge an additional fee for physicals as this may result in double billingresult in double billing.

11

PPACA’s Effect on Concierge PracticePractice

• Under PPACA Medicare pays for mostUnder PPACA, Medicare pays for most preventive “screening” services if the physician providing the services acceptsphysician providing the services accepts Medicare assignment.

• Can physicians continue providing• Can physicians continue providing concierge services?

Y b t ’t h f dYes, but can’t charge for any covered preventative screening.

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• Other services a concierge physician canOther services a concierge physician can continue to charge extra for: – Same and next day appointments– 24/7 physician contract– Emailing the physician (maybe)– Prescription facilitation – Claims facilitations

C di ti f l ( b )– Coordinating referrals (maybe)– Travel medical services – Home visitsHome visits

13


• To protect against liability concierge physicians p g y g p ymust: – Know what screening and preventive services are

and are not covered by Medicareand are not covered by Medicare – Provide patients with a description of services in the

retainer agreement – Provide patients with a summary of what is being

billed to Medicare and what extra amounts the patient owes

– Never bill a patient for services provided by Medicare – Repay Medicare immediately if you change a patient

for a covered servicefor a covered service 14


• How Fee for Service Providers areHow Fee for Service Providers are Impacted:

PPACA requires that a physician is enrolled in– PPACA requires that a physician is enrolled in Medicare to write a prescription for durable medical equipment and home health servicesq p

• PPACA gives the Secretary of Health and Human Services the authority to add to this list of services

• Physicians opting out of Medicare loose the ability to provide all the necessary care to their patients

15

Concierge Medicine: Key Legal Considerations Best Practices to Comply with Medicare Regulations

June 22, 2011

Best Practices to Comply with Medicare Regulations

,

Julie KassJulie Kass410-347-7314

[email protected]

www.ober.com

Medicare Reimbursement Issues Participating physicians Medicare pays physicians 80% of fee scheduleMedicare pays physicians 80% of fee schedule

directly Physician bills patient co-payment of 20%y p p y 80% plus 20% is payment in full

Non-participating physicians Non-participating physicians Patients pay physician

P ti t k i b t f M di Patients seek reimbursement from Medicare Limiting charge 115% of Medicare

www.ober.com17

Medicare Reimbursement Issues

Opting Out

Physician has private agreement with Medicare Physician has private agreement with Medicare beneficiary and Medicare is not billed by physician or patient for any services provided byphysician or patient for any services provided by physician

Review Medicare’s Opt-Out rules carefullyReview Medicare s Opt Out rules carefully Be certain to properly opt out before billing any

patientspatients Failure to properly “opt-out” renders any contracts

entered into with Medicare beneficiaries void and

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entered into with Medicare beneficiaries void and nullifies the physician’s decision to opt-out

Medicare Reimbursement Issues

Physicians who opt-out may not receive ANY remuneration from Medicare, including sharing inremuneration from Medicare, including sharing in practice income where other practice physicians have not opted out for two years

Other physicians in practice are not required to opt-outp

Recognize that opt-out is for two years

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Prohibition

Physicians cannot charge patients for services already covered by Medicarealready covered by Medicare

Applies to participating and non-participating physiciansphysicians

Violation of assignment agreement and carries civil money penaltiesmoney penalties

Opt-out physicians are not subject to rule

www.ober.com20

Government Pronouncements

2002- Congress sent letter to HHS and OIG Alleged that fees charged by MDVIP violated Alleged that fees charged by MDVIP violated

Medicare limiting charge rules and false claims act

HHS response did not call practices illegal as long as charges were for non-covered servicesas charges were for non covered services

Cautioned that physicians entering arrangements should seek legal counselshould seek legal counsel

www.ober.com21

Government Pronouncements

2004- OIG Alert to physicians about added charges for covered servicesg 2004 OIG settlement with physician for Personal

Health Care Medical Care Contract with $600 $annual fee 2007 OIG settlement for over $100,000 with $ ,

physician in North Carolina allegedly violating Civil Money Penalty Law for violating assignment

tagreement

www.ober.com22

OIG Roadmap for New Physicians: Avoiding Medicare Fraud and Abuse OIG education materials to teach physicians

Issued in 2011 Issued in 2011

Specifically discusses “’boutique, concierge, retainer’” practicespractices

Explains that can’t get paid a second time for a Medicare covered serviceMedicare covered service

IMPORTANT – Explicitly states that it is legal to h f i t d b M dicharge for service not covered by Medicare

Access fees or administrative fees are not allowed h th t bt i M di d i

www.ober.com23

where they are to obtain Medicare covered services

OIG Roadmap for New Physicians: Avoiding Medicare Fraud and Abuse Specifically notes CMP settlement Physician paid $107 000 to resolve allegations of Physician paid $107,000 to resolve allegations of

charging patients annual fee for Medicare covered servicescovered services

Fee covered

Annual physical, same or next-day appointments, dedicated support personnel, around the clock physician availabilityaround the clock physician availability, prescription facilitation, expedited and coordinated referrals, and other amenities at

www.ober.com24

coordinated referrals, and other amenities at the physician’s discretion

OIG Roadmap for New Physicians: Avoiding Medicare Fraud and Abuse Alleged violation of assignment agreement because

SOME of the services were already covered bySOME of the services were already covered by Medicare

Legality of agreement turns on what additional fees Legality of agreement turns on what additional fees cover

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Guidelines for Contracting With Patients

AMA Ethical GuidelinesAMA k l d th t t i t t AMA acknowledges that retainer contracts enhance patient choice and pluralism in the delivery and financing of health care. y g

However, AMA is concerned that a proliferation of retainer practices might “threaten access to care”retainer practices might threaten access to care

The AMA provides that retainer contracts:

B t d i t ith t d ith f ll Be entered into without duress, with full disclosure (including any knowledge the physician has regarding the patient’s

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physician has regarding the patient s insurance coverage)


AMA Ethical Guidelines

Th AMA id th t t i t t Must be cancelable without financial penalty or “undue

inconvenience”

The AMA provides that retainer contracts:

inconvenience

Cannot promise “more or better diagnostic and therapeutic services” p– a guideline which conflicts with the physician’s obligation to provide

“more” in return for non-covered service fees

I AMA ti i t h i i ’ f i In sum, AMA cautions against a physician’s use unfair persuasion in the contracting process and emphasizes the need to uphold quality of care standards for both

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retainer and non-retainer patients alike

Medicare Coverage Issues

What does practice bill patient for?

Medicare prohibits billing patients for covered services beyond limiting charges

Unclear distinction between “covered” and “not-covered”

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Covered Services

Generally, routine photocopying, routine overhead (including malpractice insurance costs, heating,(including malpractice insurance costs, heating, lighting, staff salaries, etc), supplies, rent, continued education or certification fees

Certain preventative and/or screening services under Medicare

Medicare enrolled physicians with retainer practices must clearly be certain they are wellpractices must clearly be certain they are well aware of current Medicare coverage guidelines

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Covered Service?

Annual Wellness Physical

M di l ll i it Medicare covers annual wellness visit

Is it the same as an annual physical?

Many screening tests now covered

But covered under specific intervals But, covered under specific intervals

www.ober.com30

Non-Covered Services

Same day appointments

ll h cell phone access

email consultations

Lectures to patients on wellness

access that has been explicitly expanded in access that has been explicitly expanded in measurable ways

Is this enough??

www.ober.com31

Non-Covered Services

Additional or extra-ordinary services

CDs, booklets, or pamphlets prepared by the physician regarding the patient’s health, well-being or a plan to achieve eitherbeing, or a plan to achieve either

Testing or treatment that is explicitly not d b M dicovered by Medicare

Any other services which provide a genuine value and which are not part of a patient’s covered service

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Payment for Medical Records? Providing a patient with an electronic copy of the medical

records may not be sufficient to justify an additional charge Under both HIPAA and the Medicare EHR Incentive Program, patients

are generally entitled to electronic copies of their health information

HIPAA provides a right to request an electronic copy of allHIPAA provides a right to request an electronic copy of all protected health information maintained in a designated record setM i f l U i l l i f i Meaningful Use requires only an electronic copy of certain more limited “health information” – but it must be provided electronically and with 3 business daysy y Providers may not charge more than “the entity’s labor cost in

responding to the request for the copy…” for electronic copies under the HIPAA changes made by HITECH (with some

www.ober.com33

under the HIPAA changes made by HITECH (with some exceptions)

Guidelines for Contracting With Patients Where a physician runs a “dual” practice (serving both

retainer and non-retainer patients) they must provide the same level of diagnostic and therapeutic service to both

Physician must facilitate transfer of patients to other h i i h if th h i iphysicians where necessary, or, if no other physicians are

available, they must continue to treat them

Contracts should clearly and specifically describe all “non Contracts should clearly and specifically describe all non-covered” services and physicians must always be honest in their insurance or other payor billings

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For Medicare beneficiaries Contracts with beneficiaries must be available for Contracts with beneficiaries must be available for

inspection (although not necessarily filed with CMS)CMS)

Missed appointment fees may be charged, but you must charge all patients the same at theyou must charge all patients the same at the same rate

www.ober.com35

Concierge Medicine: gState Laws and

Private Insurance Contracts

Robert M. Portman, JD, [email protected]

Powers Pyles Sutter & Verville, PC

State Insurance LawUnlicensed insurance companies?

Practices that provide health care services for fixed, prepaid fee may be health plans under state insurance laws (e.g., Knox‐Keene Act in California)

No other entity in chain of treatment/payment to accept No other entity in chain of treatment/payment to accept risk/subject to state regulation (e.g., reserve requirements)

If practice goes under, patients left high & dry Ex.: Washington medical group offered their own insurance plan that was put in state receivershipplan that was put in state receivership

37© PPSV

P t ti l St t I R i t

State Insurance Law Potential State Insurance Requirements

If a concierge practice is subject to state insurance regulations, it could have to meet requirements such asregulations, it could have to meet requirements such as Capital maintenance Reserve requirements

l Filings Certificate of authority

In Florida in order to obtain a certificate of authority, an y,insurer must maintain a surplus of not less than five million dollars for a property and casualty insurer, or $2.5 million for any other insurer.

In Washington in order to obtain a certificate of authority, the insurer must maintain four to five million dollars in combined capital and surplus funds. 38

O h i l S i i i

State Insurance Laws Other Potential State Law Limitations

State law might preclude physicians who have contracts with health insurers from collecting anything other than with health insurers from collecting anything other than copayments and deductibles from patients.

Some states might also preclude or limit balance billing by out‐of‐network physicians who have no insurance contracts.

Other states might prevent HMOs and other insurers Other states might prevent HMOs and other insurers from contracting with providers whose services are not equally available to all plan members within the same lclass.

39

State Insurance Laws

S f W hi


State of Washington In 2003, Washington considered requiring concierge practices to obtain a certificate of registration as a practices to obtain a certificate of registration as a healthcare service contractor or HMO.

Instead in 2007, Washington required by law that concierge practices (or “direct practices”) must Inform patients if the practice does not accept insurance, as well as about the services they provide.y p

Return any fees held in trust, if the physician/patient relationship ends.

Only raise fees once per year Only raise fees once per year. Submit annual statements to the Insurance Commissioner.

40


State of Mar land


State of Maryland Maryland Insurance Administration 2008 report detailed certain indicators that a practice might be p gengaging in the unauthorized business of insurance: Annual retainer fee covers unlimited office visits or a limited number of

services that the physician cannot reasonably provide to each patient in p y y p phis or her panel.

No limitations on the number of patients accepted into the practice. Annual retainer fee does not represent the fair market value of the

promised services. Physician has substantial financial risk for the cost of services rendered

by other providers. The retainer agreement is non‐terminable during the contract year

and/or does not provide for pro‐rated refunds.

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State Insurance Lawsd State Limitations on Concierge Medicine

West Virginia – Determined that a physician providing care for a flat fee was operating as an unlicensed insurer.p g

New Jersey ‐ Warned that NJ physicians serving on HMO or PPO panels could not require a concierge fee, because it discriminates against HMO and PPO

ipatients. New York ‐ Issued an informal warning against double billing for services already covered by private insurance. Reoccurring Issue: Which services are covered and which are not?

42© PPSV

State Insurance Laws Positive State Trends

WVA legislature has pilot program allowing h i i /h lth li i t h id f f physicians/health clinics to charge prepaid fee for

primary care and preventive services Florida – Found that MDVIP did not require an qinsurance license because the concierge fees were not considered insurance.M h F d h P l Ph i i Massachusetts – Found that Personal Physicians Healthcare did not violate state insurance laws, and the state licensing board for physicians also found that the g p yconcierge model was legal.

43© PPSV

State Insurance LawsAnalysisMD2 model may be most vulnerableMD model may be most vulnerable provides unlimited service for prepaid fee accepts risk accepts risk

Way to reduce riskP t f i t t t? Put fees in trust or escrow account?

44

State lawsAbandonment Concierge docs must be careful in how they g ydrop patients who do not become members.

Must provide adequate notice and appropriate referrals.

Do not leave patients in unstable condition. Check state law.

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Private Insurance Contracts Balance Billing and Nondiscrimination

Most provider agreements and some state insurance f flaws preclude balance billing of covered patients for

covered services Key is to show these are not covered services Key is to show these are not covered services

However it is not always easy to distinguish what is a covered service and what is not.

E l 24/7 d t il bilit h i l i ti Examples: 24/7 doctor availability, physical examinations, and coordination of care with specialists

Notice to patients Nondiscrimination issue

46© PPSV

Private Insurance ContractsNegati e Reactions Positi e ReactionsNegative Reactions Positive Reactions Premera Blue Cross in

Washington and Blue Shield f R h f

Regence Blue Shield in Washington: extras fees okay l f d of Rochester: extra fees

violate balanced billing and non‐discrimination lawsH d Pil i H l h C

as long as for noncovered services

BCBS of Mass: will contract i h i i Harvard Pilgrim Health Care

in Mass: no longer contracts with physician groups that charge access fees

with concierge practices as long as they notify patients of nature of practice and fee structurecharge access fees

Cigna and United Healthcare in Florida and Texas: physician concierge care

structure

physician concierge care practices no longer qualify for their networks

47

D S D f A i

Private Insurance Contracts Dr. Steven D. Knope of Arizona

In 2008 Dr. Knope gave a high‐profile interview about the benefits of concierge medicine in eliminating the the benefits of concierge medicine in eliminating the interference of third party payers.

A week later, Blue Cross Blue Shield called Dr. Knope to cancel his 15 year contract stating that he had violated the contract by practicing concierge medicine.

Dr Knope explained that he does not accept insurance Dr. Knope explained that he does not accept insurance from his concierge patients, but that he still saw 100 regular patients who were covered by BCBS.

BCBS still canceled his contract and his patients were forced to find another doctor.

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Ti R d L l Ri kTips to Reduce Legal Risk

Charge extra fees only for noncovered medical services.Charge extra fees only for noncovered medical services. Take proper steps to transfer nonparticipating patients to other competent physicians.

Fully inform patients which services are covered by the annual fee, which are covered by insurance, and which will require additional out‐of‐pocket payments by the will require additional out of pocket payments by the patient.

49© PPSV

Tips to Reduce Legal Risk

When ending insurance contracts, follow the termination provisions in managed care contracts termination provisions in managed care contracts carefully.

For those who do not opt out of private insurance, do not require insured patients to pay a retainer fee as a condition of receiving covered services

To avoid bumping up against state insurance laws do To avoid bumping up against state insurance laws, do not offer all necessary medical services in exchange for a fixed, prepaid fee.

50© PPSV

Contact Information

Rob PortmanPowers, Pyles, Sutter & Verville, PC

1501 M Street, NWWashington DC 20005Washington, DC [email protected]

202‐872‐6756202 872 6756

© PPSV 51

Concierge Medicine: Contractual IssuesJoshua M. Kaye, Partner

McDermott Will & Emery LLP+1 305 347 6516 [email protected]

June 22, 2011

www.mwe.com

Boston Brussels Chicago Düsseldorf Houston London Los Angeles Miami Milan Munich New York Orange County Rome San Diego Silicon Valley Washington, D.C.

Strategic alliance with MWE China Law Offices (Shanghai)

© 2010 McDermott Will & Emery LLP. McDermott operates its practice through separate legal entities in each of the countries where it has offices. This communication may be considered attorney advertising.Previous results are not a guarantee of future outcome. The following legal entities are collectively referred to as "McDermott Will & Emery," "McDermott" or "the Firm": McDermott Will & Emery LLP, McDermott Will &Emery/Stanbrook LLP, McDermott Will & Emery Rechtsanwälte Steuerberater LLP, MWE Steuerberatungsgesellschaft mbH, McDermott Will & Emery Studio Legale Associato and McDermott Will & Emery UK LLP.These entities coordinate their activities through service agreements. This communication may be considered advertising under the rules regulating the legal profession.

What is concierge medicine

Distinguishing features of primary care concierge modelsDistinguishing features of primary care concierge models

– 300-800 patients per physician

– 24/7 availability

– Same/next day appointments

– Plan of care

– Amenities/Enhancements

– “Retainer” fee

www.mwe.com 53

Three Primary Concierge Models

Non-participation -- Opt out of Medicare and out-of-network participationNon participation Opt out of Medicare and out of network participation with commercial insurers

Participation Option #1 -- Medicare and commercial insurance participation plus charge for non covered amenities and non coveredparticipation plus charge for non-covered amenities and non-covered professional health care services

Participation Option #2 -- Medicare and commercial insurance fparticipation plus charge for non-covered amenities only

What all three models have in common – retainer fee

Key distinction among concierge practices is size of retainer fee and Key distinction among concierge practices is size of retainer fee and scope of services covered by the retainer fee

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Three Primary Concierge Models

Non-participationNon participation

– Non-participation may impair viability of concierge practice

– Non-participating practice will have difficulties in authorizing in-network referrals to specialist

– Opting out of Medicare may not solve Medicare balance billing problem in certain states (e g Massachusetts)problem in certain states (e.g., Massachusetts)

– Non-participation could jeopardize ability to participate in other locations

– Substantial majority of concierge practices participate in Medicare and with commercial insurers around the country

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Concierge Models

Participation Model

– Physician owned practice provides professional services and accepts Medicare and other insurance payments as payment for covered health care services

– Medical practice and affiliated physician remains uninterrupted with concierge patient

– Physician/patient relationship terminated and transitioned for non-conciergePhysician/patient relationship terminated and transitioned for non concierge patients

– Patient enters into a membership agreement with concierge patient

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Concierge Networks

MDVIP – 250+ (national)( )

Concierge Choice Physicians (National)

SignatureMD -- Arizona, California, Georgia, Indiana, Missouri, Montana, New York Oklahoma Pennsylvania and Washington D CYork, Oklahoma, Pennsylvania and Washington D.C

PartnerMD – Virginia

MD2 – Seattle

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Concierge Networks

Business entity will enter into membership agreement with patient/client and collect retainer fees (percentage of fee shared with physician may vary)

Business entity will enter into contractual relationship with physician and physician practice to provide amenities and support services

– Patient demographic analysisg p y

– Patient telephone survey

– Initial and follow up mailings

– Patient education seminars

P i b hi ll– Processing membership enrollments

– Staff support

– Billing & Collections of membership fees

– Electronic medical records

– After hours call center

Similar to friendly physician practice management model with limited and narrowly defined scope of management services)

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Important Considerations

Pros Cons

– Patient satisfaction• Preventive medicine

– Payor risks

– Regulatory risks• Responsive medicine

• Amenities

– Physician satisfaction

– Lack of coordination with health system and ACOs

– Abuse potential• Better economics

• Better outcomes*

• More community activities

– Discrimination concerns

– Two levels of care

• More interactive patient relationship

– Consumer choice

– Impact on referral sources

– Proliferation concern

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Indicators of Success

Duration of patient relationships

Strength of patient relationships

Reputation/Board certification

Patient demographics

Feasibility assessment and affordable price point

Communications with patients (and payors/regulators)

Staff/staff training and customer service

Managing the conversion process and transition plan for non-concierge patients

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Physician-Patient Relationship Termination

Check state laws regarding patient abandonment issuesCheck state laws regarding patient abandonment issues

Give written notice to patients

Agree to and continue providing services for a reasonable period of time (30 days)

Provide support or recommendations to assist patients in locating another physicianphysician

Offer to transfer records to the newly-designated physician

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Patient/Client Membership Agreements

Clearly specific the scope of services covered by the retainer fee Specify whether the concierge practice will accept Medicare and/or other insurance State that the retainer fee is paid in addition to and not in exchange for any co-payments,

deductibles or co-insuranceSpecify the duration of membership when the retainer fee must be paid whether all or any Specify the duration of membership, when the retainer fee must be paid, whether all or any portion is refundable or non-refundable.

Specify terms of renewal (i.e., automatic renewal versus term of one year and patient must notify practice of renewal).All th ti t t t i t th l ti hi ith t fi i l lti d b d Allow the patient to terminate the relationship without financial penalties or undue burden

Marketing materials should not be misleading nor promote better diagnostic or therapeutic services

Agreement should be easy for patient to understand and patient should execute contract g y p packnowledging that they understand the terms of the agreement.

Practice staff should walk patient through key terms of agreement.

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Contracts with Concierge Network

Consider state corporate practice of medicine and fee splitting laws

Scope of services to be provided by concierge network– Transitional services

– On-going management services

/ /– Lobbying/legal support/payor assistance

Economics

Practice size limitations (400 patients, 600 patients, 1,000 patients)

Applicability to entire practice and all locations or subset of physicians or locations? Applicability to entire practice and all locations or subset of physicians or locations?

Term/Duration

Ease of Termination

Effect of Termination Effect of Termination

Indemnification

Non-Competition and other restrictive covenants

HIPAA Business Associate Agreement

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HIPAA Business Associate Agreement

Must a Physician convert entire practice

No. However, greater potential for regulatory abuseNo. However, greater potential for regulatory abuse

Many concierge practices are structured through a concierge physician accompanied by an associate physician or mid-level physician to manage the non concierge patientsmanage the non-concierge patients,

The hybrid practice model enables a practice to simultaneously maximize revenue yet devote the lion’s share of the concierge physician’s attention to their patients.

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Concierge Medicine Websites

American Academy of Private Physicians – www.aapp.org y y pp g

Concierge Medicine Today –www.conciergemedicinetoday.com

Concierge Medicine Research Collective – www.askthecollective.org

National Organization of Retail Medicine – www.retailmedicine.org

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