According to a GAO report in 2005 approximately seventy five percent of those physicians providing concierge medicine services do not opt out of Medicare, but provide some services either as a participating or non-participating physician. Those physicians must be very careful to assure that they do not charge concierge customers for any service that might be otherwise covered by Medicare which can create a potential claim for over-billing for medicare services in violation of the False Claims Act.
Participating physicians generally agree to accept Medicare’s fee schedule amount as payment in full for all covered services they provide. They receive their payments directly from Medicare and agree to charge Medicare Beneficiaries only for any applicable deductible or co-insurance. Roughly 90 percent of the physicians who bill Medicare agreed to participate. Non-participating physicians do not agree to accept the Medicare Fee schedule as payment in full for all covered services. They are still subject to limits as to what they may charge. The limits depend on whether they seek reimbursement directly form Medicare or not. Nonparticipating physicians must accept the fee schedule for nonparticipating physicians developed by Medicare which runs about 95% of the participating physician fee schedule. When the physician does not seek reimbursement directly from Medicare, the beneficiary may be charged up to 115% of the participating physician fee schedule.
In 2004 the OIG issued an alert, “Extra Contractual charges beyond Medicare’s Deductible, Coinsurance: A potential assignment violation,” wherein it reported a settlement with a physician who advertised that his concierge practice included coordination of care with other providers, comprehensive assessment and health planning and extra time with the patient.” The OIG alert did not really define where the cross over point was in billing for services provided by medicare. Medicare of course pays for services that are “reasonable” and “medically necessary” by Medicare for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member. The problem is that coverage frequently depends on the circumstances of each case and Medicare coverage might apply or not for the same service depending on differing circumstances.
In identifying services for which a physician is receiving concierge compensation outside of Medicare it is important not to indicate services that may be potentially covered by Medicare. Here are some services that have been described as value added in concierge fee coverage:
Same day or next day appointments for non-urgent care;
24 hour telephone access;
periodic preventive-care physician examinations;
extended office visits;
email, cell phone and/or pager access to physician;
wellness and/or nutrition planning;
patient home or workplace consultations;
smoking cessation support;
preventative screening procedures;
stress reduction counseling;
private waiting room;
mental health counseling
online or other electronic access to personal medical records;
accompaniment to specialist appointments or procedures;
home delivery of medication by physician or staff;
priority in diagnostic tests for affiliated medical facilities;
(Source: GAO survey of concierge physicians)