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July 2014

Concierge medicine model prohibited by Blues provider affiliation agreements

Changing to concierge model voids Blues agreements with providers

If a provider who currently participates with the Blues changes from a traditional practice model to a concierge practice, he or she will no longer meet the requirements of our participation agreements. Here are details:

  • If a provider notifies us 60 days prior to changing to a concierge practice, we will allow him or her to voluntarily withdraw from Blues networks. 
  • If a provider refuses to voluntarily withdraw from relevant Blues networks, we will terminate all affiliation agreements according to the termination provision in the applicable agreement. Depending on the agreement, the decision may or may not be appealed.

Providers who either voluntarily withdraw or are terminated by the Blues are no longer eligible to receive payment directly from the Blues for services delivered to our members.

For more details about this process, refer to the applicable network agreement and provider manual on web-DENIS or contact your provider consultant.

We want to remind you that, as part of our nondiscrimination policy, Blue Cross Blue Shield of Michigan and Blue Care Network affiliation agreements do not permit the concierge medicine model.

In a “concierge” or “retainer” practice, members pay membership fees to a provider or third-party vendor for enhanced services or amenities. As a benefit of paying this “concierge” fee, members typically receive:

  • Immediate appointment access
  • Extended office visits
  • Extended or enhanced email and telephone communication
  • Care coordination between specialists, including referral coordination
  • Wellness programs and plans, genetic and nutritional counseling and risk appraisals

This model violates the nondiscrimination provision in Blues affiliation agreements because open and ready access to care would not be provided to all of our members at the same level. As a result, the following affiliation agreements do not permit concierge services: TRUST Network Practitioner Affiliation Agreement, Traditional Participation Agreement, Medicare Advantage PPO Provider Agreement and Blue Preferred PlusSM Affiliation Agreement.

Under the terms of these agreements, providers cannot intentionally segregate Blues members in any way. They also cannot:

  • Treat members in a manner or location different from other people receiving health care services
  • Treat members differently based on payment level, benefit or reimbursement policies

Additionally, many of the services that are considered to be “enhanced” in the concierge model are, when medically necessary, those that are covered services under the affiliation agreements. For example, members who would benefit from appropriate preventative care or wellness counseling should receive those services through covered office visits, written handouts, nurse counseling, etc. According to the affiliation agreements, providers should not require members to pay for services that are not medically necessary under the umbrella of an “enhanced service.”

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2013 American Medical Association. All rights reserved.
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