If you’re a patient considering joining a concierge medicine practice, you may have a lot of questions about how insurance works with the private medicine model. The laws and relationships between insurance provider and private doctor can vary from state to state and from practice to practice, but here are answers to some of the most common questions.

Do I Need Insurance to Participate in a Concierge Practice?

For most patients, the answer to this question is no, but many private physicians still recommend that patients carry some level of insurance. The monthly or annual fees for concierge medicine often cover basic and preventive care, so you might discover that you can make some changes to your existing insurance plan. It’s a good idea to still have a major medical plan or a high deductible plan for catastrophic illness or injury, and also a health savings account in case you require hospitalization or other specialty care.

What Do Concierge Fees Cover?

The costs of concierge fees and what they cover varies from doctor to doctor and from state to state, but generally they cover basic preventive care. At a traditional doctor’s office your insurance generally requires that you pay a co-pay to see the doctor for any appointments, then you pay for the full cost of any additional lab tests or procedures until you meet your deductible. Many insurance providers also require that you pay a co-insurance of around 20 to 30 percent until you reach your out-of-pocket maximum for the year.

With concierge medicine, most offices include things like general appointments, annual physicals, and consultation for wellness and preventive care in their monthly or annual fees. The concierge doctor will not bill your insurance, and you won’t be required to pay the co-pay, meet the deductible, or pay co-insurance for these basic checkups. Every concierge office is different, though, so it’s a good idea to talk to the doctor to clarify how their cost structures work.

What About Lab Fees and Other Costs?

At a traditional doctor’s office the cost of lab work or other procedures would be part of the cost you pay toward a deductible or out-of-pocket maximum. Many concierge doctors offer patients the opportunity to get lab work, imaging, medication, and basic procedures at a very reduced rate so they can pay with cash. By eliminating the need to involve insurance providers in this process, providers can often offer better prices. In addition it eliminates the need to get approval from an arbitrary third-party provider before offering services. This model is also helpful for patients that have very high deductible insurance plans or insurance that is intended for catastrophic illness or injury.

Can I Participate in Concierge Medicine if I have Medicare?

Medicare participants can definitely join a private physician’s practice, but it does require that the doctor not bill Medicare for services that are provided under the concierge medicine fees. Medicare can still help cover the cost of things like laboratory testing, medications, specialty care, and hospitalization if necessary.

What Should Concierge Doctors Know About Insurance?

Private doctors need to be aware of the laws regarding insurance and concierge medicine. If your office chooses to implement a hybrid model and bill insurance for some procedures that are not covered by your concierge fees, then your staff must be careful not to double-bill for items that are covered under the monthly or annual retainer fees. Doctors’ offices must also be careful not to double-bill Medicare for patients over 65 that have the government-provided health plan.

While it may seem like joining a concierge practice would increase costs, many patients find that they can purchase a high-deductible insurance plan and/or invest in a health savings account, pay the monthly concierge fees, and still end up breaking even or saving money by avoiding the hefty co-pays or higher premiums that come with traditional care.

Also see “How Concierge Medicine Can Help Cut Healthcare Costs”