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Legal tips for direct primary care practices

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A direct primary care (DPC) practice operates differently than a traditional independent provider’s practice, in regard to how it affects both the patient and the physician. A DPC practice, at first glance, appears to have a relatively simple model. The practice receives monthly membership fees from patients rather than charging for each visit. These membership fees cover basic primary care services and may, depending on the practice, also cover a number of coordinated care and off-site laboratory or diagnostic services.

The idea behind DPC is that physicians are able to spend more time with their patients and less time worrying about billing, insurance, and practice management. DPCs may or may not accept insurance. Those who do, bill the insurance company as a convenience for their patients or to cover services and procedures not included in their monthly fees. Some also accept Medicare payments. That is where the simple idea behind the DPC starts to get a little more complicated.

However, physicians practicing under any type of DPC model, hybrid or not, do have some legal considerations. The American Academy of Family Physicians (AAFP) recommends consulting with an attorney familiar with the DPC model who can provide “insight about local and state regulations governing the practice of retainer-based medicine and whether current insurance carrier contracts may be amendable to complementary services covered under a retainer fee.”

Elation’s Direct Care Playbook offers some helpful legal tips for DPC practices as well.

  • Review and secure appropriate malpractice insurance. Independent physicians who move to a DPC model may be able to save money on malpractice insurance. DPC physicians tend to have fewer claims than regular physicians, so they can receive a nearly 50% discount on the cost of their malpractice insurance. With significantly lower malpractice premiums, direct care physicians can more easily obtain such insurance to protect their practices against potentially damaging lawsuits.
  • Review IRS regulations and definitions. Currently, the DPC practice patient fee is not a qualified HSA expense. Likewise, even though Medicare patients are the nation’s highest utilizers of care, most are unable to receive direct care, unless they receive coverage under a Medicare Managed Care Plan.

Elation also strongly recommends that the DPC practice consult a lawyer to ensure that the physician is up to date on the latest policies and procedures that affect the practice as well as the patients.

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