concierge medicine: key legal...
TRANSCRIPT
Concierge Medicine:
Key Legal Considerations Complying With Medicare Regulations, Insurance Laws and the Anti-Kickback Statute
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TUESDAY, APRIL 17, 2012
Presenting a live 90-minute webinar with interactive Q&A
Robert M. Portman, Principal, Powers Pyles Sutter & Verville, Washington, D.C.
Julie E. Kass, Principal, Ober|Kaler, Baltimore
Thomas J. Cuccia, CFA, ASA, Managing Director, Valuation Services,
Reimbursement and Advisory Services Division, Altegra Health, Los Angeles
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Concierge Medicine: Key Legal Considerations
Overview and Practice Models
Robert M. Portman, JD, MPP
Powers Pyles Sutter & Verville, PC
Road Map Overview of Concierge Medicine and Models
Federal Legal Issues
State Law and Private Insurance Issues
Contracting Issues
Valuation Issues
6 1501 M Street NW Seventh Floor Washington, DC 20002 202-466-6550
Concierge Care a/k/a “boutique” or “retainer” medicine
Reasons for development lower reimbursement
payment denials, delays
rising malpractice premiums
greater liability risk/regulatory burdens
increasing overhead/paperwork
higher patient loads
7 1501 M Street NW Seventh Floor Washington, DC 20002 202-466-6550
Concierge Care
Potential Risks
Medicare, state insurance laws, private insurance contracts
Ethical dilemmas
Contract issues
Positive outcomes
Personal care
Professional satisfaction
May make preventative care affordable and accessible
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Common Characteristics Primary care
Fixed monthly or annual fee
Limited number of patients—300-800
Special services/attention
Greater physician access
Plan of care
Amenities
Must pay retainer to receive any services
Concierge Care
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Typical Services/Amenities
priority/extended/Sat. appointments
nicer, less crowded waiting rooms
24/7 pager/email/cell phone access
house calls/visits to specialists
preventive/wellness care
telephone/email consultations
Prescription/claims assistance
Services Provided
10 1501 M Street NW Seventh Floor Washington, DC 20002 202-466-6550
Services Provided Premium Services
Unlimited appointments
Same day appointments
All physician office services covered
Transportation
Spa-like amenities (bathrobes/slippers)
“free” x-rays
11 1501 M Street NW Seventh Floor Washington, DC 20002 202-466-6550
Practice Models Non-participation (no insurance)/all preventive and
primary care
Participation (accepts insurance)/retainer only covers non-covered services
Participation/amenities only
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Practice Models Variations
Hybrid—concierge and non-concierge services within same practice
Direct Care—retainer plus high deductible insurance
Bifurcated corporate structure
Franchise/Practice Management
Direct non-physician ownership—only in states with weak corporate practice of medicine laws
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Key Decisions
Participation vs. Non-participation
All concierge vs. hybrid
What services included in the fee
What fees to charge
Size of patient panel
Independent practice or affiliate with franchise or management company
Practice Models
14 1501 M Street NW Seventh Floor Washington, DC 20002 202-466-6550
750-2000 doctors
200,000 patients
Retainer fees ranging from $600-30,000
100-500 patients
Concierge practices in most states
All but 11 states have concierge practices (per 2010 MedPAC report)
The Numbers
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Concierge Care Examples MD2 – www.md2.com
Seattle based/closed model started in 1996
Original concierge practice
Now has offices in Portland, Chicago, and Dallas
Mercedes medicine
All the primary care you want for $13.5-20K/year
Plus spa-like amenities, physician escort for specialist visits, prescription drug pickup/drop-off service
Guaranteed same day appointments
50 families per physician
16 1501 M Street NW Seventh Floor Washington, DC 20002 202-466-6550
Concierge Care Examples MD2
Does not accept insurance
Will franchise for $75k plus 5% royalty
Goal is to create international network of similar practices
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Concierge Care Examples MDVIP—http://www.mdvip.com/
Boca Raton based closed model
Starbucks approach—over 450 physician affiliates in 32 states
$1500-1800 annual fee
600 patients per physician
Provides standard concierge services, but does not guarantee same day appointments
does not provide unlimited office-based services
does not provide spa amenities
18 1501 M Street NW Seventh Floor Washington, DC 20002 202-466-6550
Concierge Care Examples MDVIP--http://www.mdvip.com/
Does accept insurance
Will franchise turn-key operation for percentage of franchisee’s concierge fees.
Franchisee keeps all insurance reimbursements
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Concierge Care Examples Personal Physician Health Care, LLC/PC
www.personalphysicians.net
Boston based/closed model
Dual corporate structure- LLC and PC
PC accepts Medicare/private insurance
LLC provides concierge services
$5,000 per patient
300 patients per physician
20 1501 M Street NW Seventh Floor Washington, DC 20002 202-466-6550
Concierge Care Examples Health Access RI
Network of independent medical practices
Monthly membership fee of $25-30 per month
Per visit fee of $5-10
Provides primary care services
Does not accept insurance
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Concierge Care Examples Qliance Medical Management, Inc.
Seattle-based “Direct Care”—retainer for concierge services backed up by high deductible insurance
Funded by venture capital and other investors
Shows growing interest of venture capital firms in direct care model
Monthly fee of $39-79 for unlimited preventive and primary care
22 1501 M Street NW Seventh Floor Washington, DC 20002 202-466-6550
Concierge Care Examples Other Examples
SignatureMD—Arizona, California, Georgia, Indiana, Missouri, Montana, New York, Oklahoma, Pennsylvania and Washington D.C
Concierge Choice Physicians (National)
PartnerMD—Virginia
23 1501 M Street NW Seventh Floor Washington, DC 20002 202-466-6550
April 17, 2012
www.ober.com
Concierge Medicine: Key Legal Considerations
Best Practices to Comply with Medicare Regulations
Julie Kass 410-347-7314
www.ober.com 25
Concierge Medicine Under Medicare
Secretary of HHS, 2002:
Physicians participating in Medicare can charge
patients a special fee to provide services that are
not covered by Medicare
www.ober.com 26
Medicare Reimbursement Issues
Participating physicians
Medicare pays physicians 80% of fee schedule directly
Physician bills patient co-payment of 20%
80% plus 20% is payment in full
Non-participating physicians
Patients pay physician
Patients seek reimbursement from Medicare
Limiting charge 115% of Medicare
www.ober.com 27
Medicare Reimbursement Issues
Opting Out
Physician has private agreement with Medicare
beneficiary and Medicare is not billed by
physician or patient for any services provided by
physician
Review Medicare’s Opt-Out rules carefully
Be certain to properly opt out before billing any
patients
Failure to properly “opt-out” renders any contracts
entered into with Medicare beneficiaries void and
nullifies the physician’s decision to opt-out
www.ober.com 28
Physicians who opt-out may not receive ANY
remuneration from Medicare, including sharing in
practice income where other practice physicians
have not opted out for two years
Other physicians in practice are not required to
opt-out
Recognize that opt-out is for two years
Medicare Reimbursement Issues
www.ober.com 29
Medicare Prohibition
Physicians cannot charge patients for services
already covered by Medicare
Applies to participating and non-participating
physicians
Violation of assignment agreement and carries civil
money penalties
Opt-out physicians are not subject to rule
www.ober.com 30
Medicare Coverage Issues
What does practice bill patient for?
Medicare prohibits billing patients for covered
services beyond limiting charges
Unclear distinction between “covered” and “not-
covered”
www.ober.com 31
Covered Services
Generally, routine photocopying, routine overhead
(including malpractice insurance costs, heating,
lighting, staff salaries, etc), supplies, rent, continued
education or certification fees
Malpractice fees
www.ober.com 32
Covered Service?
Annual Wellness Physical
Medicare covers annual wellness visit
Is it the same as an annual physical?
Many screening tests now covered
But, covered under specific intervals
Women’s health issues: screening pap tests, pelvic
exams, and mammography
Medicare enrolled physicians with retainer practices must
clearly be certain they are well aware of current Medicare
coverage guidelines
www.ober.com 33
Non-Covered Services
Same day appointments
Cell phone access
Email consultations/texting
Lectures to patients on wellness
Claims facilitation
Home visits
Access that has been explicitly expanded in measurable
ways
Is this enough??
www.ober.com 34
CDs, booklets, or pamphlets prepared by the
physician regarding the patient’s health, well-
being, or a plan to achieve either
Testing or treatment that is explicitly not
covered by Medicare
Any other services which provide a genuine
value and which are not part of a patient’s
covered service
Non-Covered Services
Additional or extra-ordinary services
www.ober.com 35
Government Pronouncements
2002 - Congress sent letter to HHS and OIG
Alleged that fees charged by MDVIP violated
Medicare limiting charge rules and false claims
act
HHS response did not call practices illegal as long
as charges were for non-covered services
Cautioned that physicians entering arrangements
should seek legal counsel
www.ober.com 36
2004 - OIG Alert to physicians about added charges for covered services
2004 OIG settlement with physician for Personal Health Care Medical Care Contract with $600 annual fee
2007 OIG settlement for over $100,000 with physician in North Carolina allegedly violating Civil Money Penalty Law for violating assignment agreement
Government Pronouncements
www.ober.com 37
OIG Roadmap for New Physicians: Avoiding Medicare Fraud and Abuse
OIG education materials to teach physicians
Issued in 2011
Specifically discusses “’boutique, concierge,
retainer’” practices
Explains that can’t get paid a second time for a
Medicare covered service
IMPORTANT – Explicitly states that it is legal to
charge for service not covered by Medicare
Access fees or administrative fees are not allowed
where they are to obtain Medicare covered services
www.ober.com 38
Specifically notes CMP settlement
Physician paid $107,000 to resolve allegations of
charging patients annual fee for Medicare
covered services
Fee covered
Annual physical, same or next-day
appointments, dedicated support personnel,
around the clock physician availability,
prescription facilitation, expedited and
coordinated referrals, and other amenities at
the physician’s discretion
OIG Roadmap for New Physicians: Avoiding Medicare Fraud and Abuse
www.ober.com 39
Alleged violation of assignment agreement because
SOME of the services were already covered by
Medicare
Legality of agreement turns on what additional fees
cover
OIG Roadmap for New Physicians: Avoiding Medicare Fraud and Abuse
www.ober.com 40
When dealing with Concierge Practice Management Companies be sensitive to:
State Fee Splitting Prohibition: prevent a physician from sharing any part of their fees with a third-party without the third-party performing certain substantive services
e.g., often payments are appropriate, but need to be tied to the value of the services
Potential kickback issues for marketing; see Advisory Opinion 10-23 (November 4, 2010)
Potential Fraud and Abuse Issues
www.ober.com 41
Guidelines for Contracting With Patients
AMA Ethical Guidelines
AMA acknowledges that retainer contracts
enhance patient choice and pluralism in the
delivery and financing of health care.
However, AMA is concerned that a proliferation of
retainer practices might “threaten access to care”
The AMA provides that retainer contracts:
Be entered into without duress, with full
disclosure (including any knowledge the
physician has regarding the patient’s
insurance coverage)
www.ober.com 42
Must be cancelable without financial penalty or “undue
inconvenience”
Cannot promise “more or better diagnostic and
therapeutic services” – a guideline which conflicts with the physician’s obligation to provide
“more” in return for non-covered service fees
In sum, AMA cautions against a physician’s use unfair
persuasion in the contracting process and emphasizes
the need to uphold quality of care standards for both
retainer and non-retainer patients alike
Guidelines for Contracting With Patients
AMA Ethical Guidelines
The AMA provides that retainer contracts:
www.ober.com 43
Where a physician runs a “dual” practice (serving both
retainer and non-retainer patients) they must provide the
same level of diagnostic and therapeutic service to both
Physician must facilitate transfer of patients to other
physicians where necessary, or, if no other physicians are
available, they must continue to treat them
Contracts should clearly and specifically describe all “non-
covered” services and physicians must always be honest
in their insurance or other payor billings
Guidelines for Contracting With Patients
www.ober.com 44
For Medicare beneficiaries
Contracts with beneficiaries must be available for
inspection (although not necessarily filed with
CMS)
Missed appointment fees may be charged, but
you must charge all patients the same at the
same rate
Never bill a patient for services covered by
Medicare
Guidelines for Contracting With Patients
Concierge Medicine: Key Legal Considerations
State Laws
Private Insurance
Contracting Issues
Robert M. Portman, JD, MPP
Powers Pyles Sutter & Verville, PC
State Insurance Law Unlicensed insurance companies?
Practices that provide health care services for fixed, prepaid fee may be health plans under state insurance laws (e.g., Knox-Keene Act in California)
No other entity in chain of treatment/payment to accept risk/subject to state regulation (e.g., reserve requirements)
If practice goes under, patients left high & dry
Ex.: Washington medical group offered their own insurance plan that was put in state receivership
46 1501 M Street NW Seventh Floor Washington, DC 20002 202-466-6550
Potential State Insurance Requirements If a concierge practice is subject to state insurance regulations, it
could have to meet requirements such as
Capital maintenance
Reserve requirements
Filings
Certificate of authority
In Florida in order to obtain a certificate of authority, an insurer must maintain a surplus of not less than five million dollars for a property and casualty insurer, or $2.5 million for any other insurer.
In Washington in order to obtain a certificate of authority, the insurer must maintain four to five million dollars in combined capital and surplus funds.
State Insurance Law
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Other Potential State Law Limitations
State law might preclude physicians who have contracts with health insurers from collecting anything other than copayments and deductibles from patients.
Some states might also preclude or limit balance billing by out-of-network physicians who have no insurance contracts.
Other states might prevent HMOs and other insurers from contracting with providers whose services are not equally available to all plan members within the same class.
State Insurance Laws
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State of Washington
In 2003, Washington considered requiring concierge practices to obtain a certificate of registration as a healthcare service contractor or HMO.
Instead in 2007, Washington required by law that concierge practices (or “direct practices”) must
Inform patients if the practice does not accept insurance, as well as about the services they provide.
Return any fees held in trust, if the physician/patient relationship ends.
Only raise fees once per year.
Submit annual statements to the Insurance Commissioner.
State Insurance Laws
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State of Maryland Maryland Insurance Administration 2008 report detailed certain
indicators that a practice might be engaging in the unauthorized business of insurance: Annual retainer fee covers unlimited office visits or a limited number of services
that the physician cannot reasonably provide to each patient in his or her panel.
No limitations on the number of patients accepted into the practice.
Annual retainer fee does not represent the fair market value of the promised services.
Physician has substantial financial risk for the cost of services rendered by other providers.
The retainer agreement is non-terminable during the contract year and/or does not provide for pro-rated refunds.
State Insurance Laws
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State Insurance Laws State Limitations on Concierge Medicine
West Virginia – Determined that a physician providing care for a flat fee was operating as an unlicensed insurer.
New Jersey - Warned that NJ physicians serving on HMO or PPO panels could not require a concierge fee, because it discriminates against HMO and PPO patients.
New York - Issued an informal warning against double billing for services already covered by private insurance.
Reoccurring Issue: Which services are covered and which are not?
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State Insurance Laws Positive State Trends
WVA legislature has pilot program allowing physicians/health clinics to charge prepaid fee for primary care and preventive services
Florida – Found that MDVIP did not require an insurance license because the concierge fees were not considered insurance.
Massachusetts – Found that Personal Physicians Healthcare did not violate state insurance laws, and the state licensing board for physicians also found that the concierge model was legal.
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Analysis
MD2 model may be most vulnerable
provides unlimited service for prepaid fee
accepts risk
Way to reduce risk
Put fees in trust or escrow account?
State Insurance Laws
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Other State laws Abandonment
Concierge docs must be careful in how they drop patients who do not become members
Must provide adequate written notice and appropriate referrals
Do not leave patients in unstable condition; provide transition care
Check state law
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Other State laws Corporate Practice of Medicine
For franchise/practice management models, physicians must control medical decision-making
Anti-kickback (all payor)/Fee Splitting
Will affect franchise or practice management fees
Franchise Laws
Check to see if state franchise laws apply if franchise/practice management model is chosen
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Private Insurance Balance Billing and Nondiscrimination
Most provider agreements and some state insurance laws preclude balance billing of covered patients for covered services
Key is to show these are not covered services
However it is not always easy to distinguish what is a covered service and what is not.
Examples: 24/7 doctor availability, physical examinations, and coordination of care with specialists
Notice to patients
Nondiscrimination issue
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Private Insurance Negative Reactions Positive Reactions
Premera Blue Cross in Washington and Blue Shield of Rochester: extra fees violate balanced billing and non-discrimination laws
Harvard Pilgrim Health Care in Mass: no longer contracts with physician groups that charge access fees
Cigna and United Healthcare in Florida and Texas: physician concierge care practices no longer qualify for their networks
Regence Blue Shield in Washington: extras fees okay as long as for noncovered services
BCBS of Mass: will contract with concierge practices as long as they notify patients of nature of practice and fee structure
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Dr. Steven D. Knope of Arizona In 2008 Dr. Knope gave a high-profile interview about the benefits
of concierge medicine in eliminating the interference of third party payers.
A week later, Blue Cross Blue Shield called Dr. Knope to cancel his 15 year contract stating that he had violated the contract by practicing concierge medicine.
Dr. Knope explained that he does not accept insurance from his concierge patients, but that he still saw 100 regular patients who were covered by BCBS.
BCBS still canceled his contract and his patients were forced to find another doctor.
Private Insurance
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Contracting Issues Business Entity-Practice Contracts
If franchise/practice management model chosen, business entity will need to enter into contracts with participating medical practices
Contract will specify whether business entity or practice will collect retainer fees
Practice receives license to use entity’s name and logo
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Contracting Issues Business Entity-Practice Contracts
Practice should retain control over physician’s services
Specify that parties are independent contractors and company does not have control over medical services provided by practice
Practice agrees to follow company’s standards and guidelines
Fees in compliance with state AK/fee splitting laws
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Contracting Issues Sample practice contracts provisions:
Liability insurance Mutual indemnification provisions Clearly defined services company will provide for practice (see next
slide) Payment from practice to franchise company Practice model/size Services practice will provide Whether practice will accept insurance Term and termination Non-compete and other restrictive covenants HIPAA BA agreement if entity touches PHI
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Contracting Issues Franchise/Practice Management Services
Patient demographic analysis
Initial and follow up mailings; other marketing
Patient education seminars
Processing membership enrollments
Staff support
Billing & Collections of membership fees
Electronic medical records
After hours call center
Access to lower cost liability insurance and other
products/services
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Contracting Issues Patient Contracts- should contain:
Services covered by the subscription fee
What services/costs are not covered and any out-of-pocket costs
Whether the physician accepts Medicare/private insurance
When the retainer fee is payable/refundable
When services covered by Medicare or private insurance will be billed or collected
How much practice will charge for services not covered by retainer fee
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Contracting Issues Patient Contracts
Contract should specify duration of membership and whether it automatically renews or patient must affirmatively renew
Patient should be able to terminate without financial penalties or excessive inconvenience
Patient must be able to understand the contract and sign it voluntarily—practice staff assistance
Contract should not make exaggerated claims about the quality of care
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Tips to Reduce Legal Risk Charge retainer fees only for noncovered medical
services
Take proper steps to transfer nonparticipating patients to other competent physicians
Fully inform patients which services are covered by the annual fee, which are covered by insurance, and which will require additional out-of-pocket payments by the patient
65 1501 M Street NW Seventh Floor Washington, DC 20002 202-466-6550
Tips to Reduce Legal Risk
Follow carefully rules for opting out of Medicare as well as the termination provisions in agreements with managed care and other insurers
For those who do not opt out of Medicare or private insurance, do not require insured patients to pay a retainer fee as a condition of receiving covered services
To avoid bumping up against state insurance laws, do not offer all necessary medical services in exchange for a fixed, prepaid fee.; rather provide clearly defined services for retainer fee
66 1501 M Street NW Seventh Floor Washington, DC 20002 202-466-6550
Robert M. Portman
Robert M. Portman
Principal
Powers Pyles Sutter &
Verville PC
1501 M Street NW
Seventh Floor
Washington, DC 20005
202-466-6550 Main
202-872-6756 Direct
Robert M. Portman is a principal in the law firm of Powers Pyles
Sutter and Verville PC in Washington, DC. Mr. Portman
concentrates his practice in health and association law, focusing
on certification law, administrative law, antitrust law, litigation,
transactions, election and lobbying law, and legislation and
regulation in the health care field. He represents a wide range of
non-profit health care organizations including a large number of
national professional societies, trade associations, other health
care associations, voluntary health organizations and certification
bodies, as well as numerous individual physicians, physician
practice groups and other health care providers.
1501 M Street NW Seventh Floor Washington, DC 20002 202-466-6550
Concierge Medicine: Key Legal Considerations Fair Market Value Considerations
Between Practice & Patient and
Between Concierge Company & Practice
Thomas J. Cuccia, CFA, ASA Managing Director
Case Study 1 Practice & Patient
• Determine FMV of Concierge Medicine Program Annual Patient Fee – Facts to Consider
• Program Offering & Patient Benefits – Wellness Program with Annual Visit
» Wellness Plan
» Metabolic Panel, Heart Health, Diabetes Prevention
» Respiratory Health, Bone Density, Sleep, Vision, Hearing
» Comprehensive Risk Factor Analysis
» Comprehensive Lab Test Program
» 24/7 access to personal doctor, same day appointments, access to network of physicians when travelling & access to nationally renowned specialists
69
Case Study 1 Practice & Patient
• What to Consider when Determining FMV
– Internal Information
• All Promotional Literature
• Membership Application & Agreement
• Encounter Forms
• Physician Curricula Vitae
• Annual Visit CPT Codes & Description of Services with Time Estimates for Provision of Services
• Does Medicare Reimburse for Service?
70
Case Study 1 Practice & Patient • External Sources of Information
– The Centers for Medicare & Medicaid Services (“CMS”) Physician Fee Schedule (“PFS”)
– The Frank Cohen Group Advanced Healthcare Analytics – Sinaiko Healthcare Consulting’s Proprietary Paid Claims
Database – American Medical Group Association: 2010 Medical Group
Compensation and Financial Survey (“AMGA Compensation Survey”);
– Medical Group Management Association: 2010 Physician Compensation and Productivity Survey (the “MGMA Survey”);
– Sullivan Cotter and Associates: 2010 Physician Compensation and Productivity Survey (the “2010 SCA Survey”); and
– Economic Research Institute Salary Assessor (“ERI Survey”).
71
Case Study 1 Practice & Patient
• Approaches to Value
– Income – Not Relevant
– Cost – Relevant
– Market – Relevant
72
Case Study 1 Practice & Patient
• Cost Approach – Use Considered Surveys to Determine Physician
Compensation per FTE – Adjust for Time Difference between Valuation Date
and Survey Date – Add Benefits – Determine Hourly Rate & Apply to High & Low Time
Estimates – Use PFS to Determine wRVU & tRVU per CPT – Calculate Compensation per wRVU & tRVU & Apply to
wRVU & tRVU per CPT
73
Case Study 1 Practice & Patient
• Results of Cost Approach Analysis
– Total Compensation per wRVU & tRVU
75
Case Study 1 Practice & Patient
• Results of Cost Approach Analysis
– Total Compensation for Annual Wellness Visit
76
Case Study 1 Practice & Patient
• Market Approach – Reviewed Data by Frank Cohen Group
• National Average Charge Data per CPT
• Average Charge per CPT for Internal Medicine Specialty
• Average Charge per CPT for Family Practitioners
– Reviewed Sinaiko Proprietary Paid Claims Database
• Commercial Payor Reimbursement by CPT and location (physician office)
– For Lab Tests CMS Clinical Lab Fee Schedule
77
Case Study 1 Practice & Patient
• Analysis Summary – Cost approach approximates the physician compensation
received in clinical practice for provision of the services absent any other benefit available to the patients in concierge program.
– Family practice and internal medicine doctors generally earn more for specialized services such as those provided in the concierge program. The cost approach which looked at weighted average compensation per hour and compensation per wRVU and tRVU across all procedures does not adequately capture the complexity and specialized nature of the concierge services.
– The market approach approximates what the physicians would charge for the provision of comparable procedures to those offered. Does not consider the added benefits received by patients in the concierge program.
78
Case Study 1 Practice & Patient
• Conclusion
Specialty Average Charge
Internal Medicine $1,554.82
Family Practice $1,553.47
FMV Conclusion Annual Concierge Fee
79
Case Study 2 Concierge Company & Practice
• Determine FMV of Fee Concierge Medicine Company Charges Physician Practice
– Facts to Consider
• AKS Statute of Primary Importance – depends on whether physician is seeing patients participating in federal programs
• State anti-kickback and fee-splitting laws may also be implicated
80
Case Study 2 Concierge Company & Practice
• Approaches to Value
– Income – Not Relevant
– Cost – Relevant
– Market – Relevant
81
Case Study 2 Concierge Company & Practice
• What to Consider when Determining FMV – Internal Information
• All Promotional Literature
• Agreement Between Physician Practice & Company – Length of Time
– Right to Cancel
– Rights & Responsibilities of Parties to Agreement
• What Services Does Company Provide to Physicians
• Staff Providing the Services – Level of Professional
• Cost to Provide the Services
82
Case Study 2 Concierge Company & Practice
• External Sources of Information – What Companies Providing Similar Marketing
Services to Non-Physicians are Charging Clients • Reasonable Markup or Gross Margin for Marketing
Companies
– Franchise Fees for Non-Medical Arrangements
– Perhaps a Licensing Fee or Royalty Rate for use of a Trade-name
– Point One Cost/Market Hybrid Approach
– Points Two & Three Market Approach
83