Concierge medicine, sometimes called retainer medicine, involves charging patients a subscription or access fee for medical and related healthcare services. It appears that concierge medicine is here to stay, as the concierge medicine market size was valued at over $7 billion in 2024. It is no wonder, then, that many medical practitioners want to enter the concierge medicine space. However, many legal, regulatory, and practical issues need to be addressed to ensure compliance and to promote clarity in the physician–patient relationship. Here is a preview of some of these issues, along with a discussion of how concierge medicine lawyers can help navigate them.
What Is a Concierge Medical Practice?
Concierge medicine is a healthcare model where patients pay a monthly or annual fee. Once available only to the ultra-wealthy, concierge medicine has become increasingly common in recent years. It is also popular for patients, as patients receive more thorough care as well as easier access to their doctors through concierge.
By limiting the number of patients they serve, physicians can dedicate more time to each individual’s care. Concierge medicine also helps reduce administrative burdens, allowing physicians to focus on preventive care and wellness.
Concierge medicine operates under different business structures. The hybrid model involves physicians treating both concierge and non-concierge patients, while the direct primary care model opts out of federal payors to serve exclusively a defined group of member patients.
Membership/Subscription Model Issues and Challenges
The concierge care model, which requires patients to pay a membership fee before being accepted or receiving care, presents challenges, particularly to those new to concierge medicine. Here are some of the most prevalent issues:
- Being Clear About the Scope of Services
- Services included in the membership fee should be clearly defined and specified. Patients must understand exactly what their membership fee covers, including whether it includes annual physicals, same-day appointments, wellness counseling, diagnostic testing, or other services, as well as what remains billable separately or must be covered by insurance.
- Financial and Operational Decisions
- Subscription fees must be set at a level that supports the practice’s operations while providing value to patients. Practices must carefully project patient volume, overhead costs, and staffing needs.
- Insurance Implications
- An important legal consideration is whether an access fee charged by a concierge or prepaid medical practice could be deemed the business of insurance, thereby subjecting the practice or entity to state insurance regulation. While traditional fee-for-service models are generally not classified as insurance, prepaid access fees raise distinct regulatory concerns due to their structure as advance payments for a defined set of future services. In addition, the arrangement must comply with any contractual obligations the provider or entity has with private insurers or third-party payers. Many insurance contracts prohibit balance billing for covered services, and a key legal issue is whether the access or retainer fee includes services typically covered by insurance, such as physical exams, routine office visits, or diagnostic tests, potentially triggering further regulatory scrutiny.
- Terminating the Relationship
- Though concierge medicine is a subscription-based service, it is different from streaming platforms or food delivery services when it comes to ending the relationship with the patient. Both state statutes and professional ethical standards unequivocally prohibit patient abandonment, which is defined as the unilateral termination of a physician-patient relationship without providing the patient with adequate notice and a reasonable opportunity to obtain alternative medical care.
How Concierge Medical Attorneys Help Medical Professionals
Launching a concierge medicine practice brings unique legal and ethical challenges. From structuring patient agreements to navigating complex healthcare regulations, every aspect of a concierge model must be carefully planned to ensure compliance with federal and state laws. Here are some issues that skilled concierge medical attorneys can help medical professionals interested in concierge medicine work through:
Anti-Kickback and Fee-Splitting Concerns
Offering “free” services or bundled clinical and non-clinical offerings may raise red flags under the federal Anti-Kickback Statute and similar state laws, particularly when Medicare is involved. Such services can be seen by enforcement authorities as improper inducements for clinical care, potentially triggering penalties.
Contracts and Patient Agreements
Concierge practices must have clear, written agreements that define fees and the specific services provided. These contracts help avoid violations of state and federal laws, including insurance regulations, medical board rules, advertising standards, and CMS participation requirements. A failure to clearly outline terms can expose the practice to legal and regulatory risk.
Ethical Considerations
Ethical issues arise when patients do not fully understand the value, scope, or limits of the services they are paying for. Practices must ensure that offerings are transparent to support informed patient decisions and avoid accusations of misrepresentation.
Marketing Compliance
Advertising for concierge services must comply with state and federal rules governing physician marketing. All promotional materials should avoid misleading claims about access, quality, or outcomes to stay within legal limits.
Several Other Issues
Concierge medical practices, along with non-physician health and wellness entities, must navigate a complex set of federal and state legal requirements to operate lawfully and effectively. Some include:
- Corporate practice of medicine (CPM): Non-licensed individuals or entities cannot control clinical decisions, as violations may lead to penalties.
- Privacy and advertising laws: Practices must comply with HIPAA and truth-in-advertising rules to avoid misleading claims about care quality or access.
- Internal referrals: Prepaid packages that allow patients to see any provider in a practice could be viewed as unlawful inducements if owners profit from internal referrals.
Contact Our Experienced Concierge Medical Attorneys Today
Establishing a concierge medicine program requires careful legal planning and expertise. Because this model involves complex issues such as corporate practice of medicine, fee-splitting, and anti-kickback regulations, insurance law, and various state and federal compliance requirements, it is essential to work with concierge medicine lawyers who understand the healthcare regulatory landscape. Having the right legal advice helps ensure the practice follows all applicable rules, reducing the risk of fines or legal issues and allowing focus on delivering excellent personalized care. Contact us today.