5 Essential Medicare Lessons for Concierge Medicine
If there’s one universal truth about healthcare, perhaps it’s this: medical insurance is complicated.
The compliance and regulations requirements involved with Medicare can be especially headache-inducing. Concierge physicians who accept Medicare while also charging a membership fee must carefully walk the line between meeting Medicare rules and having a successful independent practice.
The good news is, no one has to figure it out alone. ROAMD members have found that they can successfully operate their membership-based practices both with and without Medicare, in a variety of scenarios. Here, we’ve compiled some of what we’ve learned over the years about concierge medicine and medicare to help you make the best Medicare-related decisions for your practice. Disclaimer: This article is not intended to replace nor serve as legal guidance.
1. What Is the Difference Between Opting Out and Unenrollment?
An often heard phrase among new private practices is, “I’m just going to opt out of, or unenroll from, Medicare to keep things simple.” It’s essential to know that these are two very different things. So, let’s explore what each really means.
By opting out of Medicare, concierge medicine practitioners can enter into a private contract with all Medicare patients. You can then collect out-of-pocket fees directly rather than billing Medicare for your services.
The opt-out process involves three main steps:
- Confirm you’re eligible to opt out of Medicare.
- Submit an opt-out affidavit to Medicare.
- Enter into a private contract with each Medicare patient in your practice.
This opt-out status renews every two years unless you submit a cancellation request more than 30 days before your renewal date. It’s also possible to terminate your opt-out status within the first 90 days of submitting your initial opt-out affidavit.
Unenrolling, on the other hand, withdraws you from the Medicare program entirely. This makes it difficult — if not impossible — to adjust your future participation with Medicare; this point cannot be over-emphasized. It’s also worth noting that unenrolled concierge physicians are not eligible to order tests, labs, and prescriptions through Medicare, while opted-out physicians still are.
2. If I Opt Out of Medicare, Do All of My Physicians and NPs Need to Also?
The complexities of Medicare are abundant, leading to confusing situations like this one. In short, yes, it’s possible to accommodate concierge medicine physicians and nurse practitioners who are opted in to Medicare even if your practice has opted out.
Nurse practitioners and other physicians who remain opted in can still operate autonomously within your opted-out practice to treat Medicare patients. That said, the circumstances for concierge medicine and medicare will be unique from practice to practice and will require due diligence and ongoing legal counsel from an attorney.
Several ROAMD members have had this concern when hiring a physician or nurse practitioner with Medicare standing that doesn’t match their practice’s opted-out status.
For example, one member’s opted-out practice in Florida recently hired a physician who requested to remain opted in so she could continue moonlighting in the local hospital. The practice carefully reviewed all their paperwork and website content with an attorney to ensure they remained in complete compliance with Medicare rules.
The bottom line? You can safely have concierge medicine practitioners whose opt-in or opt-out status contradicts your own, without breaking Medicare rules. Just remember these key points:
- Remain cognizant of how your facility bills for Medicare.
- Carefully review all public-facing wording to make sure you remain compliant.
- Talk to your legal team first, and whenever you’re in doubt.
- Remember that you may not need to opt out altogether.
3. How Can I Charge Membership Fees and Stay Compliant When Opted-In to Medicare?
When you’re opted in to Medicare and you’re charging a membership fee, concierge medicine practitioners must be hypersensitive regarding all outward-facing communication, billing, and messaging. Whether it’s your membership agreement, phone scripts, or website content, you’ll need to review all verbiage with your legal team to achieve complete Medicare compliance.
Medicare doesn’t allow practitioners to exclude any Medicare patients, which provides a unique challenge to opted-in concierge medicine physicians charging membership fees for their services. Your opted-in practice cannot treat Medicare patients differently than other populations (e.g. better access, better services, etc.).
At first, running an opted-in concierge medical practice may seem impossible. But there are some reasonable paths available in order to operate a membership practice that remains opted into Medicare.
Some concierge medicine practices strike a balance with Medicare by using phone scripts that screen potential patients and determine whether they are willing and able to pay the requisite membership fee. For example, a practice may only accept new patients referred by existing patients, rather than those who find the practice through other means. Referrals from existing patients are more likely to understand and appreciate the membership fee model.
Another option is to structure the practice’s membership pricing to account for Medicare and to prevent potential conflicts of interest. If Medicare covers a particular service, device, or treatment, it doesn’t matter if commercial insurers don’t cover it. By default, if Medicare covers it, your practice cannot charge an additional cash-based fee.
Awareness is key when working with concierge medicine and medicare. When you operate in a space outside the mainstream, you have so many more factors to remain cognizant of than the usual practice. Whether it’s pricing, your website, your phone scripts, your new patient conversations, or any other element, you have to scrutinize how it aligns with Medicare compliance and how it supports your practice.
4. What if a Patient Has a Medicare Advantage Plan?
Medicare Advantage (MA) plans add another layer of complexity to the already convoluted Medicare system.
There are literally hundreds of varying plans, so no general rule of thumb can help here. Instead, deferring to the specific MA plan to find out the terms and whether you’re covered is the best solution.
Checking each contract manually is tedious, time-consuming, and resource-draining. In order to accommodate patients with MA, the most efficient strategy is to call the specific MA plan and ask: are we in-network for this plan?
5. Can I Prescribe Medicine and Order Tests for Medicare Patients, Even if I Opted Out?
Physicians are sometimes surprised to learn that they retain certain privileges within Medicare even after opting out. The Affordable Care Act states that prescribing medications covered under Medicare part D is limited to participating, nonparticipating, and opted-out physicians.
The only providers unable to order prescriptions and tests for Medicare patients are those on the Preclusion List, which includes providers currently revoked from Medicare or convicted of a felony under state law within the last 10 years.
Conclusion
When handled with attention and knowledge, Medicare has the potential to support your when working with concierge medicine and medicare practice, not oppress it. Opting out may seem like the simplest solution — and it may be. But know that a reasonable space does exist for membership-based practices who want to continue a relationship with Medicare at some level.
Dr. Scott Pope serves as the Chief Growth Officer at In Scope Ventures, a growth consulting firm focused on early stage healthcare companies. Scott is passionate about healthcare entrepreneurship and has been involved in various advocacy efforts to promote innovation in the industry.
Scott earned his PharmD from Ohio Northern University, where he participated in Habitat for Humanity, Phi Mu Delta, Order of Omega, and NCAA basketball. After graduating from ONU, Scott completed a pharmacy residency at Cone Health, followed by a specialty residency in infectious diseases, internal medicine, and academics at Campbell University and Duke University Medical Center.
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