Physician Concierge Services

Policy No: 130
Originally Created: 06/01/2023 (Group and Individual)
Originally Created: 02/01/2017 (Medicare Advantage)
Section: Administrative
Last Reviewed: 07/01/2024
Last Revised: 07/01/2024
Approved: 08/08/2024
Effective: 09/01/2024
Policy applies to: Group and Individual & Medicare Advantage

This policy applies only to physicians and other qualified health care professionals.

Concierge services also known as; retainer medicine, boutique, platinum practice and/or direct care. These include patient-provider direct care medical services and are models of care in which a physician or other qualified healthcare professional charges a predetermined fixed monthly fee to patients for all primary care services provided in their offices, regardless of the number of visits. This typically includes routine health care services, including screening, assessment, diagnosis, treatment for the purpose of promotion of health, detection and management of disease or injury; and sometimes, it includes limited office-based laboratory or diagnostic services.

Physicians and other qualified health care professionals who provide concierge services often say their practices serve fewer patients than conventional practices to give patients more time during office visits to ask questions and receive explanations regarding medical care. Some practices may offer additional services, such as same-day appointments, extended business hours, home visits and 24-hour emergency physician availability.

Access fee care models are similar but distinct. They also assess a fixed monthly fee, but it is exclusively applied to non-covered services, such as parking, refreshments, lifestyle planning or direct cell-phone access to MDs and priority scheduling. Access fees do not typically apply to any routine covered services.

Concierge membership fees and practice access fees are not covered benefits.

Charging members priority scheduling fees outside of our provider contract causes undue hardship to our members and may not be assessed to our members.

We consider the services typically included in a concierge practice agreement to be standard, routine medical services that are already covered in all existing health plans.

Services by physicians who have opted out of Medicare are not covered for Medicare Advantage members. Under no circumstances should a Medicare Advantage Plan member be charged a membership or concierge fee for enhanced access or services.

OIG: I Physician Relationships With Payers

None