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Annual payment schedule Only two things matter when it comes to making money: What you charge, and what you get paid. Although the average fees you charge for different CPT codes have remained fairly stable over the last several years, many practices have experienced a decline in reimbursement rates. A recent government study showed that more than half of all Americans do not receive many important preventive and wellness services. Nor have they been educated about healthy habits and injury prevention. And unfortunately, 44 million Americans have no health insurance. For those individuals who are lucky to have insurance, their benefits typically do not cover wellness and preventive services. What this comes down to is this: People are responsible for managing their own preventive care. Unfortunately, they may not insist on getting preventive services, and they may be confused about what to ask for. They may not even know that prevention is usually the most economical form of medicine. A PLAN WITH MANY NAMES A new concept is creeping into American healthcare — a concept that addresses the wellness factor. This concept goes by a number of different names — retainer healthcare, boutique healthcare, executive health programs, platinum practices, and concierge care. What the concept entails is an arrangement whereby patients pay a set annual fee for uncovered services, such as wellness care. The concept is attractive to a growing number of physicians, including chiropractors, who no longer want to remain hostage to reimbursements. Through these types of plans, you can fulfill your desire to become a partner with your patient in promoting a proactive, preventive approach to health. When you go to a luxury hotel or resort, you have the opportunity to use the services of a concierge, a person devoted to providing special services to guests. That is the concept that drives these retainer health plans. Patients develop an enhanced relationship with their healthcare provider. In some of these plans, patients establish an enhanced relationship with their physician, whom they can call at any hour, who will have a leisurely discussion in their office about their health, or who will accompany them to a specialist. The physician acts as a coach on overall health programs. Boutique practices charge patients annual prepaid membership fees to provide preventive and wellness care services not covered by health insurance or managed care. The average plan charges fees of about $1,500 per patient, per year, based upon a menu of services included in the plan, as well as the needs of the patient. Generally, plans include a one-year retainer contract with automatic one-year renewals, unless either side decides to terminate without penalty on at least 30 days prior written notice. For chiropractors, these plans may only include services not covered by insurance, such as:
KEY ISSUES Although plans are developed to meet your needs and the needs of your patients, the basic components include the following: • Clearly defined responsibilities. The plan must clearly define which services are included in the payment of the annual fee, and should state the patient’s payment responsibilities. You should also go over the details of the plan verbally with patients, to make sure they have a clear understanding. • Payment schedule. As a general rule, the annual fee is payable upon execution of the contract between the patient and the physician; however, you may authorize a budgeted monthly fee arrangement to accommodate patient needs. • Not a replacement for insurance. Patients must understand that this type of wellness plan does not take the place of insurance. There is a clear line between wellness and preventive services and the diagnosis and treatment of illness and injury. Patients should have insurance for hospitalization, specialists, and drugs. A concierge plan covers wellness. You still bill Medicare and commercial insurers for the diagnosis and treatment of illness and injury. The plan’s fee does not affect co-payments, co-insurance, or deductibles. • Insurance-contract compliance. Doctors who set up a retainer healthcare plan have to be careful not to violate provider agreements they have with private insurance companies. For example: Some agreements prohibit balance billing of patients in a manner that could prevent charging any amounts to enrollees of those health plans, even for non-covered services, making those patients ineligible for retainer plans. Another example: If a participating provider requires patients to pay the fee in order to access care which is covered under the terms of the patient’s benefit contract, these additional mandatory charges violate the terms of the provider’s contracts with insurers. • Medicare requirements. Medicare requires physicians to submit claims for all procedures performed on Medicare patients. Consequently, you need to define services clearly that are included within your plan’s fees and those that are not. If it is clear that your retainer fees are only for non-covered services, then such fees would not violate the Medicare rules. • Legal compliance. Every state has its own set of healthcare laws. And federal laws are complicated. Have your healthcare attorney review your plan to assure that you are complying with all state and federal healthcare laws. An area that needs legal attention concerns insurance offerings. To the extent that these practices require annual prepaid membership fees, they could be viewed as offering insurance without a license. If the physician is taking the risk of providing services for a cost greater than the fee paid to him/her, insurance statutes define the offering of insurance broadly enough in many respects to encompass such an arrangement. For example: If the plan allows patients to receive all of their primary-care services (such as unlimited office visits, physical exams, and lab tests) for a predetermined, fixed fee, the risk is transferred to the physician and the plan, in essence becomes an insurance agreement. • Health Savings Accounts. Retainer plans for wellness and preventive services not covered by health insurance are a perfect match for the growing popularity of Health Savings Accounts or HSAs. As you probably know, HSAs are tax-advantaged savings plans that may be used to cover current and future medical expenses, including preventive and wellness services not covered by insurance. Proponents of prepaid healthcare plans believe that this model of care may help salvage the careers of those physicians who have become increasingly frustrated with overbooked schedules, managed-care restraints, lack of personal and family time, and other problems that can be associated with traditional practices. Physicians enjoy dramatically enhanced professional satisfaction because they are able to devote time to patients’ preventive and wellness needs. This is healthcare the way it was meant to be — personal, accessible, and engaged. SIDEBAR:
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Mark Sanna, DC, is CEO of Breakthrough Coaching, Advertising | Classifieds | Cardpack | Datebook | Past Issues | Chiro History
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