Blue Cross updates its concierge medicine policy

As a reminder, health care providers must comply with their affiliation agreements. Blue Cross Blue Shield of Michigan affiliation agreements require providers to:

• Submit claims for covered services (i.e., services covered under a member’s benefit plan) directly to Blue Cross.
• Accept our payment for covered services as payment in full.
• Only charge the member the applicable copay or deductible (or both) for the covered service.
• Not discriminate against members based on payment level, benefit or reimbursement policies.

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

• Easy appointment access
• Extended office visits
• Enhanced email and telephone communication with doctors
• Care coordination (including referrals) between the concierge practice and specialists
• Wellness programs and plans, genetic and nutritional counseling, risk appraisals

Policy changes
Blue Cross Blue Shield of Michigan has made some changes, as follows, to its concierge medicine policy since we wrote about it in the July 2015 Record:

Health care practitioners who wish to use this model in their practice won’t be eligible for any value-based reimbursement through Blue Cross and Blue Care Network programs such as, but not limited to, Physician Group Incentive Program-related VBR opportunities through the Patient-Centered Medical Home designation program or other programs.

Also, practitioners must ensure that the requirements of the concierge model are permitted by their affiliation agreements with Blue Cross.

Providers may charge a concierge fee if:

• Patients aren’t required to pay the concierge fee to become or continue to be a patient in the practice.
• Patients aren’t required to pay the concierge fee to obtain access to the provider and are only permitted access to ancillary providers, such as physician assistants or nurse practitioners, if they don’t pay the concierge fee.
• The services or products being offered as part of the concierge fee aren’t considered “covered services” under our affiliation agreements, but instead aren’t covered under a member’s benefit plan. Because benefit structures vary significantly among our members, providers are expected to understand each member’s benefit structure to ensure that covered services aren’t included in the concierge fee.
• Patients who don’t pay the concierge fee continue to receive the same level of access and services as they previously received.
• Providers continue to meet Blue Cross and BCN performance standards regarding access and service.
• The concierge level of service is clearly over and above usual practice in Michigan. Complaints from members who experience a decline in service level may result in Blue Cross concluding that the practice is noncompliant with the nondiscrimination clause of our affiliation agreements.