WELCOME!
The Do’s And Don’ts of Direct/Subscription
Reimbursement Practices
A Discussion on Implementing the Direct Care/Subscription Models for
Integrative Health Practices
James J. Eischen, Jr., Esq.
W E W I L L B E G I N M O M E N TA R I LY …
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An Evidence-Based Protocol Review
SPECIALIZING IN THE COMPOUNDING OF PATIENT
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TODAY’S
PRESENTER:
James J. Eischen, Jr., Esq.
 Owner/Senior Partner at Higgs, Fletcher & Mack
 25+ years of experience as an attorney in
California
 4+ years of experience in the healthcare field:
medical groups, EHR firms, health coaching
enterprises and healthcare products.
 Studied at the University of California School of
Law, emphasis in corporate/real estate.
 Professional Memberships: San Diego County
Association Law & Medicine, Attorney-Client
Relations Committee, State Bar Of California
Section Member
This presentation is the exclusive property of
James Eischen, Jr., Esq.
and may not be reproduced or distributed in any form
without written permission from Mr. Eischen.
For more information call 619-819-9655
or email eischenj@higgslaw.com
Direct/Subscription Medicine Generally
Defined
History, evolution, various models
IT’S COME A LONG WAY
 Washington
 Qliance
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 Florida
 MDVIP
 Expansion with confirmed FFNCS model
compliance
 Fee For Non-Covered Service
(c) 2013 James J. Eischen, Jr., Esq.
Current Typical Integrative Medicine
Reimbursement Practices
Cash Basis/Fee for Service
FEE FOR SERVICE (FFS)
Does FFS work?
Consensus = NO
(c) 2013 James J. Eischen, Jr., Esq.
“The way we pay doctors is profoundly flawed. We need to move
rapidly away from fee-for- service and embrace new ways of
paying doctors to encourage cost-effective, high quality care.”
http://telemedicinenews.blogspot.com/
(c) 2013 James J. Eischen, Jr., Esq.
(c) 2013 James J. Eischen, Jr., Esq.
One problem is that the current fee-for-service system makes it difficult to coordinate after-hours care with
a patient's regular doctor. This is problematic considering that providers that know a patient well, or at the
very least have a patient's medical record, are able to give better quality of care.
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In 2010, 40.2 percent of people said their primary care clinics offered extended hours, such as at night
and on weekends.
One in five people found it very difficult or somewhat difficult to reach their clinician after hours.
People that reported less difficulty reaching a physician after hours had fewer emergency department
visits (30.4 percent compared to 37.7 percent).
Furthermore, there were lower rates of unmet medical needs (6.1 percent compared to 13.7 percent).
http://www.ncpa.org/sub/dpd/index.php?Article_ID=22692
(c) 2013 James J. Eischen, Jr., Esq.
Structural Problems Of Fee For Service
Reimbursement
Sporadic Utilization, Menu-Driven
Utilization/Reimbursement Distorting
Service Delivery
(c) 2013 James J. Eischen, Jr., Esq.
(c) 2013 James J. Eischen, Jr., Esq.
Applying Direct/Subscription
Reimbursement Models To Integrative
Medical Practices
(c) 2013 James J. Eischen, Jr., Esq.
WHY CONCIERGE MEDICAL SERVICES?
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Average annual fee = approximately $1,800
> 4,000 physicians practice privately in the United States in 2012
Private physician averages about 350 patients
Medicare changes = doctors reimbursed less for care provided
Concierge patients get
 more face-time with doctors
 more thorough annual physicals
 focus on preventive medicine
Concierge fee makes up for lost revenue from declining reimbursements
http://www.ncpa.org/sub/dpd/index.php?Article_ID=22781
(c) 2013 James J. Eischen, Jr., Esq.
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Concierge medicine delivers excellent care in a manner that is attractive to physicians.
Question: Whether it has the potential to fix many of the more serious problems that exist in our system for
delivering primary care.
 Affordability
 Reducing the number of patients that concierge-practice physicians see significantly reduces the
number of patients served by each primary care physician.
Retainer-based medicine remains attractive to doctors and patients in many regards. But significant questions
remain about whether it should be promoted as a model that can meet the needs of most patients in society
even with the advent of hybrid models.
(c) 2013 James J. Eischen, Jr., Esq.
The Psychological and Financial
Benefits of Subscription vs. Fee
for Service Cash Reimbursement
 Following The Trend Away From FFS
 Why change?
(c) 2013 James J. Eischen, Jr., Esq.
WHY AMERICA PERFORMS POORLY ON NEARLY
EVERY MEASURE OF HEALTH
(c) 2013 James J. Eischen, Jr., Esq.
WHY AMERICA PERFORMS POORLY ON NEARLY
EVERY MEASURE OF HEALTH
(c) 2013 James J. Eischen, Jr., Esq.
Already, one in five physicians is restricting the number of Medicare patients in their
practice and one in three primary care doctors – the providers on the front lines of
keeping the cost of seniors’ care low – are restricting Medicare patients, according to a
2010 AMA survey of more than 9,000 physicians who care for Medicare patients.
http://www.forbes.com/sites/brucejapsen/2013/01/30/1-in-10-doctor-practices-flee-medicare-to-concierge-medicine/
(c) 2013 James J. Eischen, Jr., Esq.
(c) 2013 James J. Eischen, Jr., Esq.
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U.S. has a large and widening "mortality gap" among adults over 50 compared with other high-income nations.
Two-thirds of the difference in male life expectancy between the U.S. and other countries is due to deaths in that under-50 age
category, and one-third of the gap is due to deaths among women under 50.
U.S. fares worse in nine health domains: birth outcomes, injuries and homicides, teen pregnancies and sexually transmitted infections,
HIV/AIDS, drug-related mortality, obesity and diabetes, heart disease, chronic lung disease, and disability.
Areas in which the U.S. is not behind other wealthy countries are cancer screening and mortality, control of high blood pressure and
cholesterol, smoking rates, and suicides.
Part of the nation's poor ranking attributed to problems with its $2.6 trillion-a-year health care system (the world's most expensive by
far). 50 million Americans without health insurance, fewer doctors per capita, less access to primary care and fragmented
management of complex chronic diseases.
http://www.npr.org/blogs/health/2013/01/09/168976602/u-s-ranks-below-16-other-rich-countries-in-health-report
(c) 2013 James J. Eischen, Jr., Esq.
PATIENT BUY-IN/INVESTMENT IN HEALTH
 Investing in health
 Owning health outcomes
 Realizing actual costs of poor health decisions
(c) 2013 James J. Eischen, Jr., Esq.
REMOVING MENU DISTORTIONS FROM
HEALTH CARE DELIVERY
 Subscription model as financially viable
 Subscription = payment for counseling and
medical direction disconnected from plan-funded
intervention
 Subscription = compensation for
connection/tracking/coordination
(c) 2013 James J. Eischen, Jr., Esq.
INCENTIVIZING CUSTOMER SERVICE/RETENTION
 Remaining connected vs. one-off consults
 Patient accountability only possible with persistent
connection
(c) 2013 James J. Eischen, Jr., Esq.
STABILIZED PRACTICE CASH FLOW
 FFS = financial disincentive to connect with
medical practice
 Subscription = investment in connection,
incentive to remain connected
(c) 2013 James J. Eischen, Jr., Esq.
COMPLIANCE ISSUES WITH
DIRECT/SUBSCRIPTION MODELS
 A Roadmap for New Physicians: Avoiding
Medicare and Medicaid Fraud and Abuse,
U.S. Department of Health & Human
Services and Office of Inspector General
 http://oig.hhs.gov/compliance/physician
-education/index.asp
 Private reimbursement compliance
issues
(c) 2013 James J. Eischen, Jr., Esq.
(c) 2013 James J. Eischen, Jr., Esq.
https://oig.hhs.gov/complia
nce/physicianeducation/index.asp
(c) 2013 James J. Eischen, Jr., Esq.
OIG: NO “DOUBLE BILLING”
 If you are a participating or non-participating
physician, you may not ask Medicare patients to pay
a second time for services for which Medicare has
already paid
 Charging an “access fee” or “administrative fee” that
allows patients to obtain Medicare-covered services
from your practice constitutes double billing
 It is legal to charge patients for services that are not
covered by Medicare
(c) 2013 James J. Eischen, Jr., Esq.
MEDICARE ASSIGNMENT COMPLIANCE
 Avoiding billing for covered services
 Avoiding billing for “buzz words”
 Watch out for:
 Access
 Care coordination
 Membership (?)
 24/7 comunications (?)
 Electronic records access
(c) 2013 James J. Eischen, Jr., Esq.
STATE LAW INSURANCE ISSUES
 Avoiding appearance (or reality) of insurance
 Why?
 Lack of adequate capitalization
 Lack of registration
 State law violation of insurance
regulations
(c) 2013 James J. Eischen, Jr., Esq.
HIPAA/PRIVACY COMPLIANCE (PARTICULARLY
WITH ELECTRONIC COMMUNICATIONS)
 Final/Omnibus Rule updated
 Electronic data storage of any kind = HIPAA
 Basic rules:
 Privacy
 Security
 Add: Accounting (for cash paid services)
(c) 2013 James J. Eischen, Jr., Esq.
DISCOUNTING, REBATES, INSURANCE PLAN CO—
PAYS/DEDUCTIBLES: AVOIDING IMPROPER
INCENTIVIZING UNDER STATE/FEDERAL LAWS
 May not “incentivize”
 No free toaster oven
 Co-pays and deductibles
(c) 2013 James J. Eischen, Jr., Esq.
Proper Practice Formation
PHYSICIAN-PATIENT AGREEMENT FOR
HEALTHCARE SERVICES
 Necessary to confirm compliant billing model
 Also need ePHI license for risk
management/HIPAA compliance
(c) 2013 James J. Eischen, Jr., Esq.
EPHI/ELECTRONIC COMMUNICATION
AGREEMENT (RISK MANAGEMENT)
 Privacy Rule
 Security Rule
 Documented permissions
(c) 2013 James J. Eischen, Jr., Esq.
HIPAA COMPLIANCE DOCUMENTATION
 Notice of Privacy Practices (NPP)
 Business Associate Agreement (BAA)
 Internal risk analysis
 Practice’s office procedures and
processes must be examined thoroughly
(c) 2013 James J. Eischen, Jr., Esq.
CHECKING MARKETING/PRACTICE
COMMUNICATIONS FOR COMPLIANCE
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Website
FAQs
Patient letters
Staff training!!!
(c) 2013 James J. Eischen, Jr., Esq.
QUESTIONS?
James J. Eischen, Jr., Esq.
Office: (619) 819-9655
Email:
Eischenj@higgslaw.com
Skype:
jeischenjr
http://www.assessmentandplan.com
http://www.higgslaw.com
(c) 2013 James J. Eischen, Jr., Esq.
THANK YOU!
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