Can a Fixed Benefit Plan Reimburse Direct Primary Care Visits?

This is the least-known pairing in the direct primary care world and, for some patients, the one that comes closest to paying for the membership. It relies on a category of supplemental insurance called a fixed indemnity or fixed-benefit plan, and on a piece of paper most DPC practices have never been asked to produce.

How a fixed-benefit plan pays

Major medical insurance pays providers based on what was billed and what the plan allows. A fixed indemnity plan does something simpler: it pays you a set cash amount when a covered event happens. A physician office visit might pay $120. A lab draw might pay $80. An in-office procedure might pay $200. The amounts are in a schedule, the money comes to you rather than the practice, and it does not matter whether the visit cost $300 or was covered by a membership. Carriers such as Philadelphia American sell these plans in Florida through licensed agents, and they are not a substitute for major medical coverage.

Where DPC comes in

A DPC member sees the doctor more than most people, because visits are unlimited and there is no copay to discourage them. Every one of those visits is an event a fixed-benefit plan can pay on, if it is documented. The documentation is an itemized statement, called a superbill, showing the provider's name, address and NPI, the date of service, each service with its CPT procedure code and a diagnosis code, and a dollar charge for each line. The patient photographs it and uploads it through the carrier's portal, and the carrier pays the scheduled benefit for each eligible line.

A worked example

Consider a member whose visit includes an office visit, a lab draw and an in-office injection. On a plan that pays $120 for the visit, $80 for the lab and $200 for the procedure, that single appointment produces $400 in benefits paid directly to the member. A member with hormone therapy or a chronic condition managed monthly can see benefits that offset a large share of the membership fee and other health spending over a year. The exact figures depend on the plan schedule and the services actually received.

What the practice has to do

Very little, once it is set up. The practice builds one master superbill template with its provider information, its common services and their CPT codes, common diagnosis codes and a standard charge for each service. When a member visits, staff enter the name and date and check the services delivered. The charge must show a real dollar amount rather than $0, because carriers pay against a charge; the practice sets a reasonable standard price even though the membership covered the visit. The member submits it. The practice can submit on the member's behalf as a courtesy, but without an assignment of benefits the payment still goes to the member.

The catches

• It is not major medical. A fixed-benefit plan does not cap your costs or satisfy ACA coverage requirements. It sits beside a Marketplace plan, a health share or Medicare, not in place of them.
• Pre-existing conditions. Many policies look back 12 months before the effective date and limit benefits for those conditions during the first 12 months of coverage. After the first year the limitation typically ends.
• Not every line pays. Only services on the plan's schedule are eligible, and dispensed medications and cosmetic services generally are not.
• Get the schedule in writing before you count on it, and have a licensed agent match the plan to the services you actually use.

This pairing is one of the specific things the coverage partner on each county page sets up: the plan, the benefit schedule, and the superbill template with the practice, so that the paperwork takes the practice thirty seconds and the member thirty seconds more.