Many doctors feel the involvement of an insurance company or other third party payer in the practice of medicine is a source of headaches for their medical practice. Nothing on the horizon seems to indicate that red tape, administrative burdens, and an arbitrary manner by which some insurers and other payers decide when and how claims get paid will abate. There seems to be no chance that a third party payer’s involvement in the practice of medicine will make rendering patient care better and easier. So what should doctors do to make a happy living providing care? How can patients afford and get the care and attention they need to protect their health?
The inevitable choice for many primary care doctors (and patients) is direct primary care, or “concierge” medicine. The driver of this model is obvious: no more insurance company (or, at least, a lot less third party payer involvement in medical practice). For consumers, concierge plans are no longer just for the wealthy, but are affordable for most individuals and families. For a direct monthly fee, often less than a cell phone bill, “members” get personalized, ready access to a doctor who can take the time to get to know them and help them stay healthy. Primary care physicians will see concierge medicine grow as an opportunity in coming years, particularly with the unavoidable commotion and difficulties the Affordable Care Act (ACA) will cause all providers and patients as myriad struggles in ACA implementation unfold.
Primary care doctors that get serious about evaluating a concierge business model will also realize, however, that this business model presents particular legal pitfalls that must be carefully dealt with to ensure the viability of the business over the long term. Some potential issues to be considered and addressed, for example, concern:
– the unlicensed practice of medicine in states where the “treating” doctor does not have a license (if, for example, the doctor is consulting by email with a patient who has moved his residence)
– compliance with HIPAA privacy and security rules in a practice that relies more heavily upon electronic communications
– private payment running afoul of Medicare rules and prohibitions regarding charges to Medicare beneficiaries for services that are covered under Medicare
– adherence pharmacy and DEA rules concerning prescription refills regulations concerning what tasks can be delegated to non-MD employees
– merging rules governing the practice of telemedicine and of charging for it
– the possibility that risk-assumption in providing unlimited visits/consultations for a fixed fee might be deemed an unauthorized insurance operation
– malpractice and Medical Board concerns over the sufficiency of diagnosing and prescribing treatment if the doctor has not adequately determined the patient’s history or examined the patient
Nevertheless, the proper legal steps to properly set up and operate a direct primary care practice are manageable and, as thousands of doctors are finding, far less onerous than dealing with insurance companies. To be sure, direct primary care/concierge medicine is the wave of the future.
Our business and healthcare law firm is a boutique practice focused on helping physicians and other healthcare businesses in Georgia and South Carolina make more money and sleep better. Our law firm is AV-rated, with offices in Atlanta and Augusta, Georgia. You can contact us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta) or firstname.lastname@example.org.
*Disclaimer: Thoughts shared here do not constitute legal advice.