Insurers, doctors at odds over concierge care

Here is an article that appeared in my local newspaper, the Houston Chronicle:

Concierge Medical Practice Consultant

Doctors who charge an annual fee to patients in exchange for customized care including house calls are drawing the ire of some health insurance companies. United Healthcare confirmed it is dropping four local doctors from its network in April because the company disapproves of their so-called "concierge medicine" model. Cigna is also condemning the practice, in which physicians charge an annual retainer of $1,500 to $1,800 for patients who then receive more personal care. Cigna would not say whether it is dropping any Houston-area physicians, but spokeswoman Gwyn Dilday said, "Charging membership fees to guarantee access is a violation of our contract terms and may result in termination."

Concierge medicine is a relatively small movement in the U.S. Typically, physicians who charge an upfront annual fee reduce their caseloads, which allows them to make house calls and focus on wellness matters from weight management to depression. Some give patients their cell phone numbers. Proponents say concierge care is a revolt against the modern health care system where diminishing Medicare and insurance payments have forced doctors to herd dozens of sick patients through their offices in five-minute increments every day.

While some medical specialists have chosen to stop dealing with insurance companies entirely, with patients paying for every visit in full at the time of service, others are trying to couple concierge care with insurance payments. United and Cigna say that's improper. Other major health insurers, including Aetna, Humana and Blue Cross Blue Shield of Texas, consider concierge care just fine so long as patients are clearly informed that the insurers will not re- imburse any of the retainer.

"Humana would not exclude doctors practicing this model of care from our networks," said Dr. Mark Netoskie, medical director of Humana, Houston. "It is the consumer's choice whether or not to pay for these additional services."

Texas law

Jennifer Ahrens, the Texas Department of Insurance's senior associate commissioner for life health and licensing programs, said Texas law is explicit for health maintenance organizations and preferred provider organizations. Physicians associated with HMOs or PPOs agree to discount the fees they bill insurers for specific patient services, but doctors who enter into these discounted-fee contracts can only charge patients related co-payments or co-insurance and not additional fees.

Ahrens acknowledged that concierge care in Texas is so new she wasn't aware some doctors charging annual fees were also filing claims with insurance companies.

Waiting for a complaint

"Most doctors charging these fees are trying to get away from health insurance entirely," she said. "We haven't explored this issue as it intersects with the insurance code yet. I wish someone would bring a complaint to us."

United Healthcare spokeswoman Cheryl Randolph said the concierge model "directly conflicts" with the insurer's contract with the doctors.

"Consumers and employers already pay premiums. These doctors say their fee goes toward extra services, but, for the most part, they're already covered," she said.

Darin Engelhardt, president of MDVIP, a national network of 210 physicians who practice concierge medicine, disputes that. According to MDVIP, the physicals that patients get are all-encompassing, including stress tests and EKGs not typically covered by insurance. MDVIP doctors serve 70,000 patients in 21 states and Washington, D.C.

Randolph said United Healthcare covers annual physicals and house calls.

House calls

"If doctors choose to make house calls, they can bill them to us just like they do an office visit," Randolph said. The four physicians United is dropping, including two MDVIP members, declined comment or could not be reached. In a written statement, Engelhardt said the company still hopes to resolve the issue. "Our national network of physicians remain in-network with most of the insurance companies in which they participate, and MDVIP maintains excellent relationships with a number of national and local insurers," he said. Explore the benefits of concierge medicine with REED TINSLEY, CPA. Discover how personalized care can revolutionize your practice.