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DPC and Insurance
DPC exists to take care of primary care services which do not make sense to finance through insurance. People do not use their car insurance for oil changes or filling up gas. In healthcare, people shouldn’t use health insurance for chronic disease or basic urgent care. Although Direct Primary Care physicians do not accept or bill insurance, patients can still opt to use insurance for ancillary services. Most insurance products will still recognize and accept an order from out-of-network physicians (ie DPC physicians). Exceptions include:
- Medicare Advantage Plans
- HMO's
- Medicaid (state-dependent)
This means that if a patient chooses to, they can utilize their insurance for:
- Imaging
- Medications
- Lab work
- Specialist or ancillary services referrals
CONVENTIONAL INSURANCE:
Many insurances require per-certification or prior authorization for certain imaging or medications. Suggestion: when ordering what may be an expensive test/medication, give the patient an order/prescription and ask them to check with their insurance if/how this will be covered. You may need to give billing or CPT codes for some insurances (which drags you back to your system days once in a while and makes you appreciate the daily simplicity of your DPC life!).
HIGH DEDUCTIBLE PLANS:
It is often less expensive for the patient to pay cash for the test if they have a high deductible, which saves them money, and your time. It is worth having this discussion with your patient:
“I’d like to order an MRI of your knee. What is your insurance plan and what is your deductible? How much of your deductible have you met this year?”
Usual answer: “I don’t know my deductible, and I don’t know how much I have met”.
Empower the patient - give them some homework and a cost-saving carrot to entice them to do it.
“Well, I don’t anticipate this is going to need an expensive surgery and you are generally healthy. MRI of the knee would cost you around $400 at this location. If you go through your insurance with a high deductible that you have not met, it may cost around $3000-4000. It is your choice which way you would like to proceed.”
End result: Patient learns more about how their insurance works, they have been part of the cost-saving solution and feel empowered by that, and you have written an MRI order for a cash pay location without time wasted on precertification. WIN WIN WIN.
MEDICATIONS:
You may consider the same tactic with medication dispensing.
“Your medication costs $10/months through our pharmacy and $13/month paying cash with GoodRx. Why don’t we send the first month to the pharmacy, let them run your insurance and see which option is most cost-effective.”
The more your patients understand about the cost savings and the different options that they have, the more that they become invested in the Direct Primary Care model and are likely to spread the word, marketing for you.
MANAGED CARE/HMO
This one gets tricky. You must be upfront with an HMO patient. You cannot write referrals for them and they need to have an In-network PCP to do that. Some DPC physicians develop relationships with local HMO network physicians who are happy to see their patients for referrals and take a backseat while collecting the monthly capitation (with less work). Others are not. Here are some options if you decide to take HMO patients.
- Co-manage a patient with their in-network PCP
- Patients pay cash for all their services (less expensive if the deductible is high)
- Not accepting managed care patients at all
MEDICAID:
Although Medicaid can be an exception, this is state-dependent. In some states, it is illegal for Medicaid patients to pay cash to see a doctor. In other states, Medicaid has an “ordering and referring provider” status that the physician can apply for which would enable Medicaid to honor their medication and imaging orders. As this is state-specific, the best advice would be the check with physicians practicing in your state or check dpcfrontier.com for state-by-state regulations.
See Federal and State Regulations here.
MEDICARE:
It is illegal to be a medicare provider and charge cash for services that Medicare covers (Medicare fraud). Please see Working with Medicare - The Basics, and Medicare: Opting In or Out for more details.
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DPC and Insurance
DPC exists to take care of primary care services which do not make sense to finance through insurance. People do not use their car insurance for oil changes or filling up gas. In healthcare, people shouldn’t use health insurance for chronic disease or basic urgent care. Although Direct Primary Care physicians do not accept or bill insurance, patients can still opt to use insurance for ancillary services. Most insurance products will still recognize and accept an order from out-of-network physicians (ie DPC physicians). Exceptions include:
- Medicare Advantage Plans
- HMO's
- Medicaid (state-dependent)
This means that if a patient chooses to, they can utilize their insurance for:
- Imaging
- Medications
- Lab work
- Specialist or ancillary services referrals
CONVENTIONAL INSURANCE:
Many insurances require per-certification or prior authorization for certain imaging or medications. Suggestion: when ordering what may be an expensive test/medication, give the patient an order/prescription and ask them to check with their insurance if/how this will be covered. You may need to give billing or CPT codes for some insurances (which drags you back to your system days once in a while and makes you appreciate the daily simplicity of your DPC life!).
HIGH DEDUCTIBLE PLANS:
It is often less expensive for the patient to pay cash for the test if they have a high deductible, which saves them money, and your time. It is worth having this discussion with your patient:
“I’d like to order an MRI of your knee. What is your insurance plan and what is your deductible? How much of your deductible have you met this year?”
Usual answer: “I don’t know my deductible, and I don’t know how much I have met”.
Empower the patient - give them some homework and a cost-saving carrot to entice them to do it.
“Well, I don’t anticipate this is going to need an expensive surgery and you are generally healthy. MRI of the knee would cost you around $400 at this location. If you go through your insurance with a high deductible that you have not met, it may cost around $3000-4000. It is your choice which way you would like to proceed.”
End result: Patient learns more about how their insurance works, they have been part of the cost-saving solution and feel empowered by that, and you have written an MRI order for a cash pay location without time wasted on precertification. WIN WIN WIN.
MEDICATIONS:
You may consider the same tactic with medication dispensing.
“Your medication costs $10/months through our pharmacy and $13/month paying cash with GoodRx. Why don’t we send the first month to the pharmacy, let them run your insurance and see which option is most cost-effective.”
The more your patients understand about the cost savings and the different options that they have, the more that they become invested in the Direct Primary Care model and are likely to spread the word, marketing for you.
MANAGED CARE/HMO
This one gets tricky. You must be upfront with an HMO patient. You cannot write referrals for them and they need to have an In-network PCP to do that. Some DPC physicians develop relationships with local HMO network physicians who are happy to see their patients for referrals and take a backseat while collecting the monthly capitation (with less work). Others are not. Here are some options if you decide to take HMO patients.
- Co-manage a patient with their in-network PCP
- Patients pay cash for all their services (less expensive if the deductible is high)
- Not accepting managed care patients at all
MEDICAID:
Although Medicaid can be an exception, this is state-dependent. In some states, it is illegal for Medicaid patients to pay cash to see a doctor. In other states, Medicaid has an “ordering and referring provider” status that the physician can apply for which would enable Medicaid to honor their medication and imaging orders. As this is state-specific, the best advice would be the check with physicians practicing in your state or check dpcfrontier.com for state-by-state regulations.
See Federal and State Regulations here.
MEDICARE:
It is illegal to be a medicare provider and charge cash for services that Medicare covers (Medicare fraud). Please see Working with Medicare - The Basics, and Medicare: Opting In or Out for more details.