Under Florida’s New Direct Primary Care Law, medical doctors, chiropractors, osteopaths, and nurse practitioners can now sign direct primary care (DPC) agreements with patients without having to negotiate insurance laws. While this is great news to those who want to practice DPC, this new law does nothing to relieve chiropractors from having to comply with Medicare rules.

How DPC Affects Medicare Rules

The DPC model is structured to charge a flat monthly, quarterly or annual rate for unlimited care regardless of the amount of treatment received by a patient. The problem arises when a DPC patient, or the employer group who’s paying for the employee’s DPC fees as part of the employee’s benefits package, pays more in the set monthly, quarterly, or annual fees to the DPC provider than the Medicare assignment rate for the covered medical services received by the patient.

To further illustrate this point, here is a hypothetical situation involving Patient Doe. Patient Doe, is covered by a DPC provider agreement with Dr. John’s DPC practice that is paid for by Patient Doe’s employer. Patient Doe has only seen Dr. John one time for the entire year, for a medically necessary manual manipulation of the spine. The Medicare Fee Schedule for that particular manual manipulation is hypothetically $100.00 as it is a covered and reimbursable service under Medicare. The total amount of money, however, received by Dr. John for the year from Patient Doe’s employer group for Patient Doe’s participation in Dr. John’s DPC program is $1200.00 ($100/month).

Under this scenario, Dr. John has run afoul of Medicare regulations and False Claim Act laws. This happened because Dr. John violated his assignment agreement with Medicare by requesting and receiving payment of $1200.00 for a covered service that according to the Medicare Fee Schedule, Dr. John should have only billed and received $100.00.

In order to avoid this type of situation, primary care physicians and other providers are advised to opt-out of Medicare. But Chiropractors are not permitted to opt-out of Medicare.

Chiropractors and Direct Primary Care

In order for chiropractors to practice DPC, they must structure their practice as a hybrid; providing traditional fee-for-service care for Medicare and other government health programs and DPC care for those patients who aren’t beneficiaries of government health plans. While this may seem impossible, it is not.  Patient services and corresponding agreements can be delivered and drafted in such a way as to not run afoul of Medicare Rules.  An experienced DPC attorney who has structured these types of DPC practice agreements is key. Kathrine Nicol is an expert legal advisor for DPC practice start-up and regulatory compliance. Contact her today to discuss converting your practice to the Direct Primary Care model.

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