10 key dos and don’ts for direct primary care

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Physicians and groups frustrated with the administrative burden of filing and contesting insurance claims on behalf of patients — or those who simply wish to manage a smaller patient panel — might wonder whether the direct primary care (DPC) practice model is right for them. In a DPC practice, the provider does not participate in any health care insurance plan.

Typically, patients pay a periodic membership fee and in exchange receive a suite of services for no charge or a minimal charge. This suite of services can include same or next-day appointments, home and hospital visits, and direct access to providers outside of office hours. Patients are charged on a fee-for-service basis for all additional services.

DPC is different from concierge practices where the provider often participates in health insurance plans and charges a fee for additional services not typically covered by insurance.

The DPC model is built to be attractive to practitioners and patients alike because the time providers would otherwise spend on insurance claims can be spent on patients. In analyzing whether the DPC model is right for your practice, here are 10 dos and don’ts to consider:

1. DO consult with an experienced health care attorney to help navigate the complexities of the DPC practice model and the application of state and federal laws.
   1. If you currently participate in health plans, an attorney can assist with identifying obligations in your provider contracts that you might not be aware such as provisions that restrict when and how you can terminate contracts and provisions requiring continuity of care that may go beyond what state law requires.
   2. Since patients pay a fixed fee in advance for medical services, some states have cautioned practitioners that the DPC model might constitute the practice of insurance, which would require them to obtain an insurance license and comply with the state’s insurance laws.
2. DO decide if you want to set up a pure DPC practice or a hybrid arrangement where you allow “pay as you go” patients who choose not to join as members.
3. DO consider the maximum number of patients you would be willing to bring on and whether you have the appropriate staff and resources.
4. DON’T ignore patient abandonment issues if a patient does not wish to join as a member, has a medical condition that requires continuity of care, or the number of patients on your panel has reached your upper limit. Offer to refer these patients to your local medical society, which can provide information about physicians who are accepting new patients.
5. DO have patients sign a membership agreement that includes key provisions including, but not limited to: (a) a list of services covered and not covered by the membership fee; (b) a clear statement that membership is not an insurance plan or a substitute for an insurance plan; and (c) a provision that patients should carry health coverage to comply with federal law and to cover services not provided by the DPC practice.
6. DO price the membership carefully. Look at what other DPC practices in your area are charging. Some DPC practices offer a discount for family memberships, while others charge a non-refundable registration fee and/or a nominal per-visit fee.
7. DO consider whether you want to offer a “superbill” that members can submit to insurers for services not covered by membership and services provided to “pay as you go” patients. If you do not plan to offer or wish to assist patients with the superbill, make this clear in the membership agreement.
8. DON’T ignore Medicare and other government programs. Some DPC practitioners choose not to see Medicare patients, while others opt out of Medicare. A provider who opts out may enroll and charge Medicare beneficiaries and also has the option to order, prescribe and refer certain services. If you are enrolled in Medicare and do not opt out, you may unknowingly be subject to severe penalties if a Medicare beneficiary submits a claim for a service included in the membership fee.
9. DO consider whether you will offer telehealth. If you do, patients should sign a separate telehealth consent. In addition, make sure you comply with state law regarding any patient disclosures that may be required.
10. DO reserve the right to terminate a patient immediately under certain circumstances, such as failure to comply with the membership agreement or abusive or threatening behavior toward staff.

Often the biggest decision in considering the DPC practice model is the leap of faith that enough patients will be attracted to the idea of more personalized medical attention that they will pay out-of-pocket for this benefit. Please contact one of our health care attorneys if you would like more information about the DPC model or if you have other questions regarding your health care practice.

Margaret A. Bartiromo, Stephen M. Cowherd and Isabelle Bibet-Kalinyak are attorneys in the Health Care practice at the law firm Pullman & Comley with offices in Connecticut, Massachusetts, Rhode Island and New York.