By Lee Lasris
Going Concierge? What you may need to know.
Concierge medicine has been around for decades. With physicians having to spend more and more time on nonproductive documentation activities with less time available for patient care, we continue to see an interest in physicians considering whether concierge medicine is a good move for them. Such practice models are certainly legal here in Florida and HHS has long ago determined that concierge-style agreements are permitted as long as the requirements of the Medicare program are followed. In part 1 of this 2 part blog, we will cover the recent Florida statute authorizing direct primary care agreements.
Direct Primary Care Agreements – Florida Law
Before the Florida legislature addressed the issue of direct primary care arrangements, in legislation which became effective July 1, 2018, medical providers offering such contracts, a type concierge practice for primary care patients, may have been deemed to be operating a prepaid health clinic or a prepaid limited health services organization. Florida law requires that such organizations obtain a certificate of authority from the Office of Insurance Regulation and comply with a plethora of insurance regulations and solvency protections typically out of reach of most small practices.
The newly enacted Florida law eliminates those concerns and expressly exempts direct practice contracts between a primary care provider and the patient from the Florida insurance code. In order to qualify for exemption under §624.27, Fla. Stat. According to the statute a direct primary care agreement must:
Be in writing and signed by the provider and the patient.
Be terminable by either party upon 30 days advance written notice or immediately upon breach of the physician-patient relationship or the agreement.
Describe the scope of the primary care services covered by the monthly fee.
Specify the monthly fee and any other fees for primary care services not covered by the monthly fee.
Specify the duration of the agreement and any automatic renewal provisions.
Offer a refund if the provider ceases offering primary care services for any reason.
Include the following statement: “This agreement is not health insurance and the primary care provider will not file any claims against the patient’s health insurance policy or plan for reimbursement of any primary care services covered by the agreement. This agreement does not qualify as minimum essential coverage to satisfy the individual shared responsibility provisions of the Patient Protection and Affordable Care Act, 26 USC §5000A. This agreement is not workers compensation insurance and does not replace an employer’s obligations under chapter 440, Florida statutes.”
This statute essentially eliminates third-party payers from the primary care physician/patient relationship. The typical direct primary care model requires a contract between the physician and the patient that eliminates third-party payers from the relationship and requires the patient to pay a monthly fee for specified primary care services, including office visits, annual physicals, routine laboratory tests, vaccinations, treatment of wounds and bone fractures, routine testing such as echocardiograms and colon cancer screening, and other primary care procedures. In exchange for the monthly fee, the patient gains access to such services, and other routine preventative services described in the contract at no additional charge.
The benefit to the physician is the elimination of certain overhead costs associated with the billing and collection process. The benefit to the patients is the ability to access a wide range of primary care services at a fixed cost. The new law takes such contracts out of the jurisdiction of the OIR by declaring that such contracts are not insurance products subject to OIR regulation. By the same token, such contracts typically do not qualify as insurance coverage that meet the minimum essential coverage standards under the Affordable Care Act.
Primary care providers desiring to incorporate a direct primary care contract in their practice should seek counsel and advice as to the preparation of a model contract that will comply with state law. Provider should be careful not to violate Medicare law which will cover in Part 2. In Part 2 we will cover the rules applicable to the provision of concierge type services to Medicare patients, including limitations on billing for Medicare cover services and the procedures for opting out of Medicare.
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