Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 07|01|2006 POLICY LAST UPDATED: 07|05|2023

OVERVIEW A concierge, boutique, or retainer practice (“concierge practice”) is a Primary Care Practice designed to offer an enhanced relationship between a patient and a primary care physician, for which the patient pays an annual fee or retainer for additional services that are not Covered Health Services, or services that are required as outlined in the primary care physicians contract or administrative policies with BCBSRI and/or its general policies and procedures. Prior to this revised policy, physicians that offered this practice model were excluded from network participation with BCBSRI. BCBSRI acknowledges a Commercial member’s choice to receive these enhanced services from a concierge practice and will allow concierge practice providers to participate in the plan’s provider network, assuming they meet all of BCBSRI’s standard network credentialing and contracting requirements and follow all of BCBSRI participation requirements.

MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION
Not applicable POLICY STATEMENT Medicare Advantage Plans and Commercial Products
Retainer/access fees are not covered by BCBSRI. Network providers may not apply retainer/access fees towards services that are covered under the member’s contract, nor should BCBSRI be billed for any concierge practice fees. Claims for all Covered Health Services shall be submitted, and provider shall only be able to collect all applicable copayments, coinsurance, or deductibles as outlined in the Members benefit plan. Providers must adhere to all requirements of their participating provider agreement. Billing practices of practitioners will be monitored to ensure compliance with both their Physician Agreement, Administrative Policies, BCBSRI Policies and Procedures and the Subscriber Agreement.

Charging Medicare beneficiaries (including Medicare Advantage members) a retainer is a violation of Medicare statutes and regulations, unless the physician has opted out of the Medicare program and contracted with the beneficiary on a private basis. Services by physicians who have opted out of Medicare are not covered for Medicare Advantage Plans members. Under no circumstances should a Medicare Advantage Plans member be charged a retainer fee.

Commercial Products BCBSRI will consider concierge practitioners who have a designation of primary care practitioner (Internal Medicine, Family Medicine, and Pediatrics) and who meet all BCBSRI Credentialing Requirements as qualifying to participate in the network as a primary care physician.

Providers must identify themselves as concierge upon initial application to become participating providers. Providers who are already participating in the BCBSRI network must provide 90-day written notice to BCBSRI detailing their intent to establish a concierge practice, including details on whether they will be operating exclusively as a concierge practice or a partial concierge practice. This notice should be sent via email to ProviderRelations@bcbsri.org.

Payment Policy | Physician Concierge Services

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

Providers who exclusively offer concierge services to all their patients should refer BCBSRI patients who do not wish to participate in the concierge program to another network provider or refer Subscribers to customer service for assistance in obtaining a new Primary Care Physician.

Providers who offer both non-concierge and concierge services to patients should make it voluntary for BCBSRI Subscribers and may not discriminate against the non-concierge patients in terms of access to medical care, the quality or comprehensiveness of care the patients receive following all of the requirements in the Providers Physician Agreement, Administrative Policies, Policies and Procedures and the Subscriber Agreement.

BCBSRI reserves the right to identify concierge providers in provider directories and/or remove them from the directory at BCBSRI’s sole discretion.

BCBSRI Patient Center Medical Home and Quality Programs Providers who require BCBSRI Subscribers to participate in concierge practices in order to receive services from the provider, do not qualify for the program; including but not limited to any and all funding provided by BCBSRI for Patient Centered Homes or BCBSRI Quality Programs at BCBSRI’s sole discretion. Providers who charge any fees for supplemental services beyond those covered/required by BCBSRI, and who warrant that the fees charged are strictly voluntary and not required to be a patient of the practice, must agree to and comply with the following conditions, in writing with the patient, before acceptance into the program:

1. The providers must make it clear that no fee, charge or payment of any kind is required of a Subscriber in order to become and/or remain a patient attributed to the primary care physician or medical practice (other than the payment of ordinary deductibles, co-pays and co-insurance under the member’s BCBSRI Subscriber Agreement);

2. There must be no differences in the treatment, care, access, responsiveness, engagement, communications, etc., provided to Subscribers who do not pay the fee compared to those who elect to pay the fee;

3. The provider has established office procedures and processes in such a way that a Subscriber could not misconstrue a voluntary fee for supplemental services as a requirement to receive Covered Health Services; and

4. The provider must also recognize (not required to be in writing between the primary care physician and the patient) and agree that BCBSRI maintains the right to audit compliance with these assurances, which may include a survey of the provider and medical practices’ Subscribers/patients who are BCBSRI members.

   If BCBSRI determines that any provider or medical practice has not abided by any requirements in this Policy, the provider/medical practice will be subject to termination from the BCBSRI network.

   COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable physician services section. BACKGROUND A concierge, boutique, or retainer practice is one that claims to offer additional comprehensive preventive care and personalized service to its patients. Physicians that offer this type of practice model, charge an access fee to patients for these enhanced services. This access fee is usually stated to provide patients with “additional services” such as 24/7 direct access to the physician, enhanced coordination of referrals, extensive clinical work-ups, and personalized wellness plans that are not part of a typical Physicians practice and are

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

over and above those services required by BCBSRI of all Primary Care Physicians. Physicians in concierge practice models typically reduce their patient panels significantly to provide these additional services to fewer patients. In return, the physician gains revenue through the access fee.

Note: This Policy shall not be considered support of development of concierge practices by BCBSRI. In fact BCBSRI has concerns related to the proliferation of these practices and will closely monitor concierge practices and will take immediate action and or a change in its policy if BCBSRI is made aware of any issues related to the access or quality of care received by all of its Subscribers.

As noted in the The American Medical Association (AMA) Code of Medical Ethics Opinion 8.055 - Retainer Practices:

"Concern for quality of care the patient receives should be the physician’s first consideration. However, it is important that a retainer contract not be promoted as a promise for more or better diagnostic and therapeutic services. Physicians must always ensure that medical care is provided only on the basis of scientific evidence, sound medical judgment, relevant professional guidelines, and concern for economic prudence. Physicians who engage in mixed practices, in which some patients have contracted for special services and amenities and others have not, must be particularly diligent to offer the same standard of diagnostic and therapeutic services to both categories of patients. All patients are entitled to courtesy, respect, dignity, responsiveness, and timely attention to their needs."

CODING Not applicable

RELATED POLICIES None PUBLISHED Provider Update, September 2023 Provider Update, November 2022 Provider Update, May 2021 Provider Update, November/December 2018 Provider Update, May 2017 Provider Update, June 2016
Provider Update, July 2006 Provider Update, March 2008

REFERENCES

1. American Medical Association, Opinion 8.055 - Retainer Practices https://journalofethics.ama-assn.org/article/ama-code-medical-ethics-opinions-financial-incentives-and- conflicts-under-various-models-payment/2013-07
2. MLN Matters Number SE0421, OIG Alert About Charging Extra for Covered Services
   https://oig.hhs.gov/documents/other-guidance/911/FA033104AssignViolationI.pdf

3. United States Government Accountability Office, Report to Congressional Congress, Physician Services, ConciergeCareCharacteristics and Considerations for Medicare. http://www.gao.gov/new.items/d05929.pdf.
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   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS