As insurance reimbursement rates continue to decline and patient caseloads continue to increase in traditional insurance-based settings, it’s not surprising that interest in alternative practice models is growing among PTs and OTs.
It’s natural to search for ways to offer the high-quality, effective care patients deserve without sacrificing income or the sanity of the providers.
However, navigating the details of these emerging care models can be confusing at best. Let’s dive into the nitty-gritty of this particular approach to rehabilitation, with an emphasis on common payment models.
Untangling Payment Systems – Understanding the difference between payment systems in concierge medical practices and concierge rehab.
Concierge Payments – The types of payment systems you might offer as a concierge PT/OT.
(Medicare) Payment Compliance – Compliance considerations for any payment system in a concierge practice. (This is extremely important!)
Untangling Payment Systems – Understanding the difference between payment systems in concierge medical practices and concierge rehab.
Concierge Payments – The types of payment systems you might offer as a concierge PT/OT.
(Medicare) Payment Compliance – Compliance considerations for any payment system in a concierge practice. (This is extremely important!)
A Therapist’s Simple Guide to Get Paid and Maintain Sanity
Concierge Care in Medicine vs. Rehab:
Differences in Payment Models
As it happens, the variations in concierge care are just as perplexing for physicians as they are for rehab professionals. In 2015, the American College of Physicians noted the wide variety in terms being used to describe concierge practices—including cash-only, boutique, and retainer medicine—and developed a single descriptor to reduce confusion: direct patient contracting practice (DPCP).
They defined a DPCP as:
“…any practice that directly contracts with patients to pay out-of-pocket for some or all of the services provided by the practice, in lieu of or in addition to traditional insurance arrangements, and/or charges an administrative fee to patients, sometimes called a retainer or concierge fee, often in return for a promise of more personalized and accessible care.” (1)
As this wordy definition demonstrates, there is also a lot of variation in the way these types of practices are run and how they make money. One common denominator in most—but not all—of these practices is the retainer or concierge fee that patients pay to “belong” to the practice. (2)
This membership fee is designed to provide a steady stream of income to the practice, typically to permit the providers to see fewer patients per day and therefore spend more dedicated time with each patient. (3)
Retainer fees vary widely as well, depending on the amount of physician access and the additional perks provided. As of 2017, the average retainer fee nationwide was approximately $135 per month. (4)
Typically, concierge patients have access to as many office visits and in-office procedures as they need; because they pay the retainer fee, patients are not responsible for co-insurance or co-pays for these services. (5)
Many concierge medical practices will bill their patients’ health insurance for the services and procedures performed in office visits. (6) However, a subset of practices do not accept any insurance plans; these are often termed “direct pay primary care” or “cash-only” practices. (7, 8) These practices may include the cost of all care in the retainer fee, collect flat rate payments only for the services rendered (without charging a retainer), or offer a combination of the two. (9)
Regardless of the payment model, patients in these practices still need to carry health insurance of some kind to cover catastrophic events and more complex procedures, such as surgery. Many patients enrolled in a concierge practice will select a high-deductible plan, and they may use funds in a health savings account (HSA) to help cover the cost of the retainer fee. (10, 11)
How Are Independent Concierge Rehab Payments Different From Concierge Clinics?
Unlike many concierge medical providers, it is rare for a concierge PT or OT to accept insurance. The argument against accepting insurance in concierge rehab is two-fold:
- Many providers entered concierge practice specifically to escape the constraints of insurance-based rehab
- Choosing not to accept insurance significantly reduces overhead and the amount of support staff needed to operate the practice. (12) This benefit is particularly appealing to therapists branching out into solo practice.
If they choose not to bill insurance as a provider, many therapists offer to provide itemized bills to patients wishing to seek out-of-network reimbursement from their insurance companies. (13)
It is difficult to find examples of concierge PT or OT practices that charge a retainer fee in the fashion of concierge medicine. This is where the lines between concierge and cash-pay therapy start to blur. If the practice does not accept insurance of any kind and does not charge a concierge fee, what differentiates it from a cash-pay practice?
One of the more popular payment models in both cash-pay and concierge rehab practices is the package-based approach, in which discounted rates are offered when a patient purchases a bundle of visits or treatments. Some examples:
- An orthopedic or sports physical therapist might offer a package of 5-10 visits to “get back on track” after an injury or a period of decreased activity.5
- A pelvic health PT or OT could offer a post-partum rehab package for new moms looking to prevent or treat issues that arise after childbirth.
- A geriatric specialist might advertise a fall prevention program with a fixed number of visits spaced out over several months.
While a clear definition of concierge rehab remains elusive, here’s what we do know: choosing a concierge-like practice model allows providers more control over how they bill for services, regardless of the payment model they choose. (14)
Medicare Compliance Considerations for Concierge Care Payments
Even in the concierge and cash-pay world, rehab providers can’t completely escape the complexities of the insurance infrastructure. For example, Medicare rules explicitly state that physical therapists cannot accept out-of-pocket payments for covered services from Medicare beneficiaries. (15)
Medicare considers a service to be “covered” if it is:
- Medically necessary to prevent or slow the deterioration of a patient’s condition; and
- Must be performed by a skilled provider (PT or OT). (16)
Many therapists in cash-only practice will elect to either operate as a non-participating provider or have no relationship with Medicare. Note that these choices are NOT the same as “opting out” of Medicare – PTs and OTs are not permitted to simply opt out of the Medicare program. (17)
- If you enroll as a “non-participating” provider, you may accept cash at the time of service from Medicare beneficiaries, but you must still submit a claim to Medicare so that Medicare can reimburse the patient. You can charge slightly more for your services than the amount approved by Medicare, but this overage is capped at 15% more than the baseline amount for non-participating providers. (18)
- If you choose to have no relationship with Medicare, you are prohibited from providing “skilled therapy” to Medicare beneficiaries. You can charge your cash pay/concierge rates for wellness or fitness interventions which are not covered by Medicare, but as soon as you cross the line into skilled physical or occupational therapy, you run the risk of being non-compliant. (19)
While not all of your potential patients will be Medicare beneficiaries, recall that many commercial insurance companies still follow Medicare guidelines, at least in part. This is where working with a knowledgeable attorney who specializes in healthcare law can save you endless headaches.
We hope this whirlwind tour of concierge payment models provides a jumping-off point for you to learn more about exciting developments in the rehab world. AC Health is here to help you grow and innovate, every step of the way!
