For providers interested in simplifying the provider-patient relationship, one option is direct primary care. Ironically, though, simplification can be complicated, particularly when the government is involved. One of the greatest hurdles to medical practice simplification is the role of Medicare on both the patient side and provider side. Any physician interested in the direct primary care (DPC) model should be very careful about how his/her practice interacts with the Medicare Program. The goal of this post is to clarify and stratify the different Medicare related risks a provider could encounter when establishing a DPC practice.
The first natural question about DPC is: what is DPC and why is it appealing? The answer is that the current healthcare system is a behemoth, surpassing the three trillion dollar mark back in 2012. In addition to its growth in size, the healthcare industry is growing in complexity. When a patient or insurance company pays for healthcare, that payment is being divided into more and more pieces every day. Some payments will cover the cost of the physician’s visit itself, but a larger percentage of the payment will go elsewhere in the system, covering administrative costs, technology, equipment and other providers. Many physicians probably dream of a future where they can cut out the middleman, having the physician-patient relationship remain just that – a relationship between a patient and their physician. Well the future is here, and it looks a whole lot like the past. Some innovative physicians and practices are engaging in a direct primary care model in order to simplify the medical relationship between providers and patients. This relatively “new” model is actually just a different form of a model that has been around for centuries – a model that allows patients to communicate directly with their physician at any time. Enrollment in a direct primary care program allows a patient to call or text their provider at any time about any primary care concern, usually with unlimited in-person visits.
The DPC model can be attractive to both physicians and patients. Because the DPC model allows physicians to keep a higher percentage of each dollar paid, they are not forced to maintain large patient panels and can focus more time and attention on the small group of patients who have DPC subscriptions. This is also an advantage for patients, allowing patients to spend more time with their providers and granting quick and easy access to medical advice through a simple text, email, or call.
Although this model is taking off, there are some hurdles a physician must overcome before engaging in direct primary care. In the private insurance world, insurers could either contract to prohibit physicians from engaging in this style of care, or could contract with physicians to provide DPC to the patient panel. Essentially, the individual provider will need to negotiate with insurance carriers to determine the fasibility of DPC in a private pay world. Aside from general concerns about not having the right patient panel to support the model, private payer obstacles, or distaste for the idea of always being accessible via cell phone, there are also some regulatory barriers physicians must get past to engage in DPC.
More than nine out of ten primary care physicians accept Medicare, which means they can bill Medicare directly for any care they provide to Medicare enrolled patients and receive payment from the government. Unsurprisingly, the Centers for Medicare and Medicaid Services (CMS) would not be happy if a physician tried to double bill for their services by charging both the government and the patient. In fact, this exact arrangement is prohibited by CMS, and if a provider who engages in DPC bills Medicare, and then also charges a subscription fee to a Medicare enrolled patient, they could be subject to the False Claims Act.
To legally engage in DPC, physicians need to consider how they interact with the Medicare program. There are three ways to avert the risk of a False Claims Act (FCA) issue in the DPC world: (1) by controlling the provider’s enrollment status with Medicare; (2) by controlling the patient population; or (3) by controlling the payment process. These methods to control risk are summarized in the table below. The green cells indicate that the strategy used will be an effective way to control risk in a DPC model. The yellow cells indicate that a provider should only use this strategy with care and attention to detail. The red cell indicates that this strategy places the provider at risk for False Claims Act liability.
DPC models can reap many benefits for both providers and patients, if properly used. However, providers need to be aware of the risks involved in establishing such a model and how that might affect their overall practice. For example, a physician who opts not to enroll in Medicare, or to dis-enroll from the program may carry little risk in a DPC practice, but if the model does not work for them, they may be restricted from re-enrolling in Medicare for a time. If physicians remain involved in Medicare as a “non-participating” provider, they may carry more administrative burdens such as submitting all Medicare claims individually without the benefit of automatic assignment. If providers are fully enrolled in Medicare or are “non-participating” providers and they fail to properly screen their patients to determine if they are in fact Medicare beneficiaries, they could carry a risk of FCA violation. The best advice for providers considering DPC? Plan ahead, create a detailed procedure for monitoring the interaction of Medicare and your DPC patient base, and audit your practice frequently for compliance with your procedure.