How Insurance Works with Concierge Medicine Practices

Concierge programs vary when it comes to commercial insurance coverage and Medicare. Some concierge medical practices take insurance, and some do not. Some submit claims for their patients, while others leave it up to their patients. 

Many concierge doctors will charge an annual fee to patients for being members of their practice and also submit insurance claims for the care they give you. Other practices may charge patients a membership fee for services that insurers do not cover while billing only for services insurance carriers do cover. 

Insurance in Traditional Medical Practices 

Most patients are familiar with how medical insurance - whether it's a government-run program like Medicare or it's from a private carrier - works. The care doctors provide is a service, and the cost for that service is split between the patient's insurer and the patient. 

Patient pay a copayment or coinsurance, and the insurer pays the rest of the doctor's bill. For example, insurance may pay a physician roughly $100 for a standard 15-minute primary care appointment. If your plan has coinsurance, you may pay $20 when you see the doctor, and insurance will pay the doctor $80.

That $20 represents a common coinsurance breakdown called 20/80 (for Medicare Part B, patients pay 20 percent of covered services). In some insurance plans, patients may pay a fixed copayment, such as $50 a visit, versus a percentage of the overall bill. 

There are other factors, of course. Has the patient met their deductible? Is the service the doctor provided covered under insurance? And is the doctor credentialed or "in network" with the carrier?

But in general, the fee a doctor pays is partially paid by the patient while the rest is paid by the insurer, whether the provider is a primary care physician, a nurse practitioner, a specialist or some other medical professional. 

Insurance in Concierge Medical Practices

In many concierge medical practices, it works the same way. Patients pay a copayment or coinsurance and the doctor bills insurance for the remainder. However, concierge practices also charge additional fees. Those fees may cover ancillary services provided by the doctor or they may merely exist just to be a member of the doctor's panel. 

Some concierge practices are out of network with insurers and patients covering the full cost of a visit or procedure. But the concierge doctor's practice provides documentation to the patient so the can seek reimbursement. 

Other concierge practices accept no insurance and operate direct primary care practices. 

Before You Join a Concierge Medical Practice

If you're considering joining a concierge medical practice, talk to the office first to find out how they handle the costs for visits and procedures and if they accept your carrier's insurance or Medicare. If they don't, they might charge an additional fee for members of their practice whose insurance they do not accept. 

HSAs and FSAs

The membership fee charged by concierge practices may be reimbursable by flexible spending accounts (FSAs) or health savings accounts (HSAs). 

FSAs, often offered by employers as part of traditional insurance plan, allow consumers to use pre-tax dollars for unreimbursed medical expenses. What's eligible is defined by law and the plan administrator. HSAs are similar. They are offered as part of high-deductible health plans and are defined by law. to find out if your fee can be reimbursed by your FSA or HSA, check with your plan administrator. 

What about MDVIP and insurance? 

MDVIP-affiliated primary care practices offer similar convenience benefits as many concierge practices, but MDVIP is not concierge. It goes beyond by offering a program focused on preventive care. 

The membership fee in an MDVIP-affiliated practices pays for the MDVIP Wellness Program, which includes services not typically covered by insurance or Medicare. Most doctors in the national network accept private insurance and Medicare for sick visits and follow ups. You can find out if an MDVIP-affiliated doctor takes your insurer by calling their office.