Concierge and membership medicine let physicians practice with smaller panels and closer patient relationships. The model also raises legal questions that a traditional practice never faces. What the membership fee buys, whether the practice stays in Medicare and its insurance networks, and how existing patients are transitioned all determine whether the practice is compliant. We advise physicians and groups in New York, New Jersey, Pennsylvania and Maryland from planning through launch and day-to-day operation.

Choosing the right model

  • Concierge with insurance billing. Patients pay a membership fee for enhanced services while the practice continues to bill insurance for covered care.

  • Hybrid practices. Part of the panel joins a membership program while the rest of the practice operates traditionally.

  • Direct primary care. Patients pay a periodic fee for a defined set of primary care services and the practice does not bill insurance for them.

Each model carries different Medicare, payor and state-law consequences, so the choice should be made with those rules in view.

Medicare and the membership fee

A physician enrolled in Medicare generally cannot charge Medicare beneficiaries extra for services Medicare already covers. Federal regulators have warned that a membership fee can violate those rules if it pays, even in part, for covered services. A compliant fee must be tied to services Medicare does not cover. Some physicians instead opt out of Medicare and contract privately with Medicare patients, a decision with formal requirements and multi-year consequences that should be made deliberately.

Payor contracts and state law

Commercial network agreements may limit what a participating physician can charge members, restrict access fees or require equal access for all plan members. Prepaid arrangements can also raise questions under state insurance law, and states take different approaches to direct primary care. We review the practice's contracts and the applicable state rules before the model is announced.

The membership agreement

A well-drafted membership agreement defines exactly what the fee covers and what it does not, explains how insurance and Medicare fit in, and addresses renewal, cancellation, refunds, after-hours access and termination. Clear terms protect both the patient relationship and the practice's position with regulators and payors.

Converting an existing practice

Conversions require care with existing patients. We plan the timeline and notices, arrange continuity of care and record transfers for patients who do not join, and coordinate the change with payors, hospital affiliations and staff, so the transition does not create abandonment or licensing exposure.

Ongoing counsel

After launch we advise on marketing, employment and contractor agreements, telehealth add-ons, HIPAA, ownership and management arrangements, and sale or succession planning for membership practices.