The Do’s And Don’ts of Direct/Subscription Reimbursement Practices

A Discussion on Implementing the Direct Care/Subscription Models for Integrative Health Practices

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James J. Eischen, Jr., Esq.

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James J. Eischen, Jr., Esq.

Owner/Senior Partner at Higgs, Fletcher & Mack

25+ years of experience as an attorney in California

4+ years of experience in the healthcare field: medical groups, EHR firms, health coaching enterprises and healthcare products.

Studied at the University of California School of Law, emphasis in corporate/real estate.

Professional Memberships: San Diego County Association Law & Medicine, Attorney-Client Relations Committee, State Bar Of California Section Member

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Direct/Subscription Medicine Generally Defined

History, evolution, various models

IT’S COME A LONG WAY

Washington Qliance

Florida MDVIP

Expansion with confirmed FFNCS model compliance Fee For Non-Covered Service

(c) 2013 James J. Eischen, Jr., Esq.

Current Typical Integrative Medicine Reimbursement

PracticesCash Basis/Fee for Service

FEE FOR SERVICE (FFS)

Does FFS work?Consensus = NO

(c) 2013 James J. Eischen, Jr., Esq.

“The way we pay doctors is profoundly flawed. We need to move rapidly away from fee-for- service and embrace new ways of paying doctors to encourage cost-effective, high quality care.”

http://telemedicinenews.blogspot.com/

(c) 2013 James J. Eischen, Jr., Esq.

(c) 2013 James J. Eischen, Jr., Esq.

One problem is that the current fee-for-service system makes it difficult to coordinate after-hours care with a patient's regular doctor. This is problematic considering that providers that know a patient well, or at the very least have a patient's medical record, are able to give better quality of care.

•In 2010, 40.2 percent of people said their primary care clinics offered extended hours, such as at night and on weekends.•One in five people found it very difficult or somewhat difficult to reach their clinician after hours.•People that reported less difficulty reaching a physician after hours had fewer emergency department visits (30.4 percent compared to 37.7 percent).•Furthermore, there were lower rates of unmet medical needs (6.1 percent compared to 13.7 percent).http://www.ncpa.org/sub/dpd/index.php?Article_ID=22692

(c) 2013 James J. Eischen, Jr., Esq.

Structural Problems Of Fee For Service Reimbursement

Sporadic Utilization, Menu-Driven

Utilization/Reimbursement Distorting Service Delivery

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(c) 2013 James J. Eischen, Jr., Esq.

Applying Direct/Subscription Reimbursement Models To

Integrative Medical Practices

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Average annual fee = approximately $1,800 > 4,000 physicians practice privately in the United States in 2012 Private physician averages about 350 patients Medicare changes = doctors reimbursed less for care provided Concierge patients get

more face-time with doctors more thorough annual physicals focus on preventive medicine

Concierge fee makes up for lost revenue from declining reimbursements

WHY CONCIERGE MEDICAL SERVICES?

http://www.ncpa.org/sub/dpd/index.php?Article_ID=22781

(c) 2013 James J. Eischen, Jr., Esq.

Concierge medicine delivers excellent care in a manner that is attractive to physicians.

Question: Whether it has the potential to fix many of the more serious problems that exist in our system for delivering primary care.

Affordability Reducing the number of patients that concierge-practice

physicians see significantly reduces the number of patients served by each primary care physician.

Retainer-based medicine remains attractive to doctors and patients in many regards. But significant questions remain about whether it should be promoted as a model that can meet the needs of most patients in society even with the advent of hybrid models.

(c) 2013 James J. Eischen, Jr., Esq.

The Psychological and Financial Benefits of

Subscription vs. Fee for Service Cash Reimbursement

Following The Trend Away From FFS Why change?

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WHY AMERICA PERFORMS POORLY ON NEARLY EVERY MEASURE OF

HEALTH

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WHY AMERICA PERFORMS POORLY ON NEARLY EVERY MEASURE OF

HEALTH

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Already, one in five physicians is restricting the number of Medicare patients in their practice and one in three primary care doctors – the providers on the front lines of keeping the cost of seniors’ care low – are restricting Medicare patients, according to a 2010 AMA survey of more than 9,000 physicians who care for Medicare patients.

http://www.forbes.com/sites/brucejapsen/2013/01/30/1-in-10-doctor-practices-flee-medicare-to-concierge-medicine/

(c) 2013 James J. Eischen, Jr., Esq.

(c) 2013 James J. Eischen, Jr., Esq.

U.S. has a large and widening "mortality gap" among adults over 50 compared with other high-income nations.

Two-thirds of the difference in male life expectancy between the U.S. and other countries is due to deaths in that under-50 age category, and one-third of the gap is due to deaths among women under 50.

U.S. fares worse in nine health domains: birth outcomes, injuries and homicides, teen pregnancies and sexually transmitted infections, HIV/AIDS, drug-related mortality, obesity and diabetes, heart disease, chronic lung disease, and disability.

Areas in which the U.S. is not behind other wealthy countries are cancer screening and mortality, control of high blood pressure and cholesterol, smoking rates, and suicides.

Part of the nation's poor ranking attributed to problems with its $2.6 trillion-a-year health care system (the world's most expensive by far). 50 million Americans without health insurance, fewer doctors per capita, less access to primary care and fragmented management of complex chronic diseases.

http://www.npr.org/blogs/health/2013/01/09/168976602/u-s-ranks-below-16-other-rich-countries-in-health-report

(c) 2013 James J. Eischen, Jr., Esq.

PATIENT BUY-IN/INVESTMENT IN HEALTH

Investing in health Owning health outcomes Realizing actual costs of poor health

decisions

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REMOVING MENU DISTORTIONS FROM HEALTH CARE DELIVERY

Subscription model as financially viable Subscription = payment for counseling

and medical direction disconnected from plan-funded intervention

Subscription = compensation for connection/tracking/coordination

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INCENTIVIZING CUSTOMER SERVICE/RETENTION

Remaining connected vs. one-off consults Patient accountability only possible with

persistent connection

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STABILIZED PRACTICE CASH FLOW

FFS = financial disincentive to connect with medical practice

Subscription = investment in connection, incentive to remain connected

(c) 2013 James J. Eischen, Jr., Esq.

COMPLIANCE ISSUES WITH DIRECT/SUBSCRIPTION

MODELS

A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse, U.S. Department of Health & Human Services and Office of Inspector General

http://oig.hhs.gov/compliance/physician-education/index.asp

Private reimbursement compliance issues

(c) 2013 James J. Eischen, Jr., Esq.

(c) 2013 James J. Eischen, Jr., Esq.

https://oig.hhs.gov/compliance/physician-education/index.asp

(c) 2013 James J. Eischen, Jr., Esq.

OIG: NO “DOUBLE BILLING”

If you are a participating or non-participating physician, you may not ask Medicare patients to pay a second time for services for which Medicare has already paid

Charging an “access fee” or “administrative fee” that allows patients to obtain Medicare-covered services from your practice constitutes double billing

It is legal to charge patients for services that are not covered by Medicare

(c) 2013 James J. Eischen, Jr., Esq.

MEDICARE ASSIGNMENT COMPLIANCE

Avoiding billing for covered services

Avoiding billing for “buzz words” Watch out for:

Access Care coordination Membership (?) 24/7 comunications (?) Electronic records access

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STATE LAW INSURANCE ISSUES

Avoiding appearance (or reality) of insurance

Why? Lack of adequate capitalization Lack of registration State law violation of insurance

regulations

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HIPAA/PRIVACY COMPLIANCE (PARTICULARLY WITH ELECTRONIC

COMMUNICATIONS)

Final/Omnibus Rule updated Electronic data storage of any kind = HIPAA Basic rules:

Privacy Security Add: Accounting (for cash paid services)

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DISCOUNTING, REBATES, INSURANCE PLAN

CO—PAYS/DEDUCTIBLES: AVOIDING IMPROPER INCENTIVIZING UNDER

STATE/FEDERAL LAWS May not “incentivize”

No free toaster oven Co-pays and deductibles

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Proper Practice Formation

PHYSICIAN-PATIENT AGREEMENT FOR HEALTHCARE SERVICES

Necessary to confirm compliant billing model

Also need ePHI license for risk management/HIPAA compliance

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EPHI/ELECTRONIC COMMUNICATION AGREEMENT (RISK MANAGEMENT)

Privacy Rule Security Rule Documented

permissions

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HIPAA COMPLIANCE DOCUMENTATION

Notice of Privacy Practices (NPP) Business Associate Agreement (BAA) Internal risk analysis

Practice’s office procedures and processes must be examined thoroughly

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CHECKING MARKETING/PRACTICE COMMUNICATIONS FOR COMPLIANCE

Website FAQs Patient letters Staff training!!!

(c) 2013 James J. Eischen, Jr., Esq.

QUESTIONS?

James J. Eischen, Jr., Esq.Office: (619) 819-9655Email: Eischenj@higgslaw.com Skype: jeischenjrhttp://www.assessmentandplan.comhttp://www.higgslaw.com

(c) 2013 James J. Eischen, Jr., Esq.

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