The Affordable Care Act authorizes what it calls direct primary care, which contemplates an arrangement by which patients can buy services directly from physicians. This is intended to be an alternative to traditional insurance relationships. Many physicians are already conducting concierge or retainer practices, and are transitioning to arrangements that are intended to fulfill the ACA requirements. Practices or groups not quite ready for direct primary or concierge care are starting down this road. They may contemplate “opting out” completely out of insurance programs. Others continue to participate in governmental and managed care arrangements, but are considering whether being fully or partially “out of network” makes sense, financially and operationally, as opposed to network provider status. Still other professionals may adopt multiple approaches.
Any such arrangements require careful planning to navigate ACA requirements as well as existing Medicare and Medicaid billing rules. State laws and managed care payer standards also come into play. ACA insurance coverage obligations and definitions specify what can be included in a direct primary arrangement. Providers who seek to “opt out” have to follow a strict protocol and need to enter into agreements with Medicare patients regarding future care. Further, payer requirements and state laws also impose limits on doctors or groups making advance for pay-per-service deals to avoid being deemed an insurer or HMO. Existing contracts may limit the ability to go out-of-network.
In this presentation, expert speaker Wayne J. Miller, Esq., will discuss the viability of direct primary care concept and how it compares and contrasts with a concierge practice. He will also address some of the myriad hurdles that can be overcome to proceed with a direct care arrangement.
Who should attend:
The presentation is intended for clinics, practice managers, physicians, medical groups and health care consultants, as well as health care facilities.
- Sue Dill Calloway
Wayne J. Miller, Esq., is a founding partner of the Compliance Law Group, Los Angeles, a law firm focused on health care industry legal compliance for clients nationwide. Wayne has practiced healthcare business and regulatory law throughout his 30-year career. His firm represents a wide range of healthcare industry clients throughout the nation. He is a frequent speaker for The Coding Institute national teleconferences on healthcare reimbursement, transactional and regulatory...
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