On March 27, Florida Governor Rick Scott signed House Bill 37 into law. The bill amended the state insurance code to allow for the direct primary care model of health care.
To date, 23 states have adopted laws related to direct primary care, making Florida the twenty-fourth state to pass legislation that would exclude direct primary care agreements from state insurance regulation.
Under direct primary care agreements, patients and/or employers are charged a monthly fee to access contractually agreed upon services in advance of the services being provided to the patient. Though the agreements are state regulated, the bottom line is that agreements between patients or employers are exempt from traditional insurance regulation.
In fact, section 456.0625 of the new Florida law states,
“A direct primary care agreement does not constitute insurance and is not subject to any chapter of the Florida Insurance Code. The act of entering into a direct primary care agreement does not constitute the business of insurance and is not subject to any chapter of the Florida Insurance Code.”
With that said, the direct primary care model should not be confused with a concierge model. Traditionally, a concierge practice is when patients pay either a monthly or an annual premium that gives them direct access to the physician and faster, more personal access to care.
In this scenario, the physician financially profits from both the additional patient premium payments and bills the insurance company for services provided to the patient. Because the concierge form of practice bills the patient’s insurance for services, the practice would still be subject to state and federal insurance regulations.
^ ^ The act of entering into a direct primary care agreement does not constitute the business of insurance and is not subject to any chapter of the Florida Insurance Code. J J
On the other hand, with the direct primary care model, services provided to the patient are paid under the agreement and cannot be billed to insurance. Under this model of care, the practice would not be subject to insurance regulation or the burden of collecting copays and denials for services.
For chiropractic physicians enrolled with Medicare, the Department of Health and Human Services is withholding comment until after the law goes into effect, but according to the American Academy of Family Physicians (AAFP), doctors can treat Medicare beneficiaries as long as the direct primary care agreement does not cover services already covered under Medicare. For chiropractic physicians, this means manipulating a Medicare patient who is under active treatment.
When consulting with senior analysts for Medicare, they related that, under Medicare statutes, a chiropractic physician who is not enrolled with Medicare would be able to provide active treatment to patients under a direct primary care model. Either way, physicians should use caution and verify this with a healthcare consultant or attorney who specializes in direct primary care practices.
The new Florida legislation goes into effect July 1, and though it doesn’t spell out how much a physician can charge under the agreement or the types of services that need to be included in the agreements, it does make clear that direct primary care agreements must be in writing, and it describes the scope of services to be covered.
Additionally, the agreement must include patient disclosures on the same page of the applicant’s signature that the agreement is not health insur-
ance. It also must state that the primary care provider will not file any claims against the patient’s health insurance policy or plan for reimbursement of any primary care services covered by the agreement. In addition, it should cover that it does not qualify as minimum essential coverage to satisfy individual shared responsibility provisions of the federal Patient Protection and Affordable Care Act is not workers’ compensation insurance, and may not replace an employer’s obligations under Florida chapter 71 - 440.
Regarding agreement retainer cost, the cost typically will be up to the discretion of the physician, his or her scope of practice, and services provided. According to a Florida Senate analysis prepared by the Florida Committee on Banking and Insurance, the average monthly fee
for most medical offices is usually between $50 to $100 per individual.
So where do chiropractic physicians fit in as primary care physicians? Previously, instituted Florida law states that chiropractors are considered primary care providers licensed under chapter 460, and the new legislation does include chiropractic physicians under the law.
The direct primary care bill goes on to define primary care service as “the screening, assessment, diagnosis, and treatment of a patient for the purpose of promoting health or detecting and managing disease or injury within the competency and training of the primary care provider.”
Providers considering direct primary care should start planning ahead to develop the legal standards for implementing a direct primary care model of health care as required by the new law. They also are encouraged to evaluate their practice to determine if this model of care is a good fit for their office.
The evaluation should include the type of practice, such as a solo chiropractic practitioner versus a multidisciplinary office. With a multidisciplinary office (practices that provide the additional services of a nurse practitioner or medical doctor), the practice would be able to offer a wider variety of services to the patient than a solo chiro-
practic practitioner by providing greater perceived value to the patient or his or her employer.
The practice should also consider the office’s average operating expenses and determine whether there is enough interest in the office’s current patient base to determine the financial validity of having a direct primary care physician practice that would provide a stable practice income.
On average, chiropractic treatment requires more treatment frequency (more office visits per month) as opposed to a medical provider, possibly diluting potential profitability in this care model. For example, if you charge a $100 monthly retainer fee and the patient comes in for treatment once a week, your total cost per visit would be $25 per visit. If the patient has an acute complaint, you may end up increasing treatment frequency and lower the monthly total cost per visit even more.
Though the direct primary care model is touted as a way to improve office efficiency, decrease dependence on insurance, and increase patient satisfaction, ultimately the decision to convert to a direct primary care practice should be based on the practice’s long-term goals and be profitable enough to provide for a stable practice income.
Florida Direct Primary Care References:
1. FI. State Senate Bill HB 37: Direct Primary Care Agreements
2. FI State Senate Bill SB 80: Direct Primary Care Agreements
3. The Florida Senate BILL ANALYSIS AND FISCAL IMPACT STATEMENT: CS/ SB 80 Banking and Insurance Committee and Senator Lee: Direct Primary Care October 11, 2017
4. The Primary Care Enhancement Act of 2017 (H.R. 365) to the U.S. House of Representatives
5. FI. Health & Human Sendees Committee
6. American Academy of Family Physicians: DPC: An Alternative to Fee-forService
7. Direct Primary Care Coalition Model State Legislation: Direct Primary Care Agreements
John Davenport, DC, serves as Insurance Director for the Florida Chiropractic Physicians Association, with over 26 years ’ experience in the chiropractic profession. He is a Certified Medical Compliance specialist, insurance consultant and founder of Compliance & Auditing Services, offering professional consulting services in billing, insurance, and HIPAA regulation. Dr. Davenport can be reached at 800-509-0538 or drjohnajhecomplianceman. com