Singularity Health Law Blog

CONCIERGE MEDICINE | MEDICARE OVERLAP TRAP

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.

MEDICARE PROVIDERS | THE “OPT OUT” OPTION.

There is a fair amount of confusion afoot concerning the obligation or not of physicians to accept Medicare patients.  There is no requirement that any physician accept Medicare patients or refrain from limiting the number of Medicare patients accepted into the physician’s practice. There are circumstances when it may be in the best interest of a physician to “opt out” of Medicare.  The growth of concierge medicine  in some respects makes it safer for physicians to “opt out” of Medicare in order to avoid stepping afoul of the Medicare fee limitations by charging for services that might be construed by CMS or the OIG as being extra contractual charges which might implicate the federal false claim statute. According to 2005, General Accounting Office Survey of providers of concierge medicine, only about 25% of them had opted out and were practicing on the cash only high wire without the Medicare safety net.

 

CONCIERGE MEDICINE: INSURANCE BUSINESS IMPLICATIONS

 As this country moves along the continuing and inevitable process of three tier medicine there has been a lot of attention directed toward the top tier of concierge medicine, which is generally more personalized and convenient care provided in exchange for an annual fee.  There are a number of different models of concierge care, but the purist contemplates a pure cash transaction for heightened or on-call services, sometimes in the home.  The concept grew out of care provided by team doctors for professional athletes hired by the Seattle Supersonics in the mid-1990’s and has expanded rapidly, particularly in Washington and Florida. Along the way, concierge medicine has raised concerns over potentially implicating state insurance laws, which vary widely in their potential application to concierge medicine.