Policy No: 130
Originally Created: 02/01/2017
Last Reviewed: 02/01/2019
Last Revised: 02/01/2018
This policy applies only to physicians and other qualified health care professionals.
Concierge services, also known as "retainer medicine" or "direct" patient-provider primary care practices (direct practices), are models of medical care in which physicians charge a predetermined fixed monthly fee to patients for all primary care services provided in their offices, regardless of the number of visits. This typically includes routine health care services, including screening, assessment, diagnosis, treatment for the purpose of promotion of health, detection and management of disease or injury; and sometimes, it includes limited office-based laboratory or diagnostic services.
Physicians who provide concierge services often say their practices serve fewer patients than conventional practices in order to give patients more time during office visits to ask questions and receive explanations regarding medical care. Some practices may offer additional services, such as same-day appointments, extended business hours, home visits and 24-hour emergency physician availability.
Access care models
Access fee care models are similar but distinct. They also assess a fixed monthly fee, but it is exclusively applied to non-covered services such as parking, refreshments, lifestyle planning or direct cell-phone access to MDs. Access fees do not typically apply to any routine covered services.
Concierge membership fees and practice access fees are not covered benefits.
We consider the services typically included in a concierge practice agreement to be standard, routine medical services that are already covered in all existing health plans. Charging for these services outside of our provider contract is a violation of the terms of the contract.
Centers for Medicare & Medicaid Services (CMS) has issued an alert reminding participating physicians, suppliers, and providers of the potential liabilities posed by billing Medicare patients for services that are already covered by Traditional Medicare or Medicare Advantage contracts. They advise that such actions are subject to civil monetary penalties and may constitute a potential assignment violation. (See References below)
CMS MLN Matters Number: SE0421
Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.