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Medicare and Membership Medicine: The Compliance Map
Concierge practices commonly keep billing insurance, including Medicare, while direct primary care, a different model, usually does not. The membership fee is legal. What it pays for is where practices get into trouble.
Updated October 2026: evidence grades replaced with evidence types; funding disclosed on every source.
Start here: the questions this brief answers
Tap a question for the short answer, then jump to the evidence.
Concierge physicians who stay enrolled in Medicare may charge a membership fee only for services and amenities Medicare does not cover. Charging for covered services is an assignment violation; the HHS Office of Inspector General warned about this in 2004 and has settled cases since. Physicians who opt out instead must file an affidavit, use compliant private contracts with every Medicare patient, and commit for renewing two-year periods. CMT reader polls point the same way the definitions do: concierge respondents were split between staying in Medicare and opting out, while most DPC respondents had opted out. In the CMT Patient Study, 43% of patients rated insurance or Medicare compatibility as highly important. Either path is workable. Neither should be chosen without a healthcare attorney.
“Medicare compliance isn't paperwork. It's trust infrastructure. A membership practice can survive a slow first year. It can't survive a compliance headline. Get it right before you launch.”
Can a Medicare-participating physician charge a membership fee?
Yes, but the fee can only pay for things Medicare does not cover, such as non-covered services or amenities. It cannot be a charge for Medicare-covered care.
Go to the full answer ↓Has anyone actually been penalized?
Yes. The HHS Office of Inspector General issued an alert in 2004 after a case involving a $600 contract for covered services, and a 2007 settlement required a physician to pay $106,600.
Go to the full answer ↓What does opting out of Medicare involve?
An affidavit filed with every relevant Medicare contractor, a signed private contract with each Medicare patient before services, and a two-year period that renews automatically.
Go to the full answer ↓How do I cancel an opt-out?
In writing, received by the Medicare contractor at least 30 days before the period ends. Late requests mean another two years; requests more than 90 days early are returned.
Go to the full answer ↓What do CMT's own polls and patient data show?
In CMT reader polls (2018 to 2021), about 48% of concierge respondents said they participate in Medicare and 34% had opted out, while about 72% of DPC respondents had opted out. In the CMT Patient Study, 43% of patients rated insurance or Medicare compatibility as highly important. These are directional, self-selected samples.
Go to the full answer ↓Which path is right for my practice?
It depends on your patient mix, fee and services. The comparison and questions in Part 5 frame the conversation to have with counsel.
Go to the full answer ↓Two paths, different rules
Every concierge practice that sees Medicare-age patients is on one of two roads. The rules on each are clear enough to follow and serious enough to respect.
Of the membership medicine practices identified in recent research (concierge and DPC combined), roughly 60% were concierge, a model that commonly continues to bill insurance, including Medicare.1 Questions about whether membership fees duplicate Medicare-covered services go back to GAO's 2005 review of concierge care.2
| Stay enrolled (participating) | Opt out of Medicare | |
|---|---|---|
| Who bills Medicare | The physician bills Medicare for covered services | No one; the patient pays the physician directly under a private contract |
| What the fee may cover | Only non-covered services and amenities | The physician sets charges for all services through private contracts |
| Paperwork | Clear membership agreement separating covered from non-covered items | Affidavit to all relevant contractors; signed private contract with every Medicare patient before care |
| Commitment | Ongoing | Two-year periods that renew automatically |
| Emergency and urgent care | Bill Medicare normally | May treat without a contract but must bill Medicare and charge no more than the limiting charge |
| Main risk | Fee found to pay for covered services (assignment violation) | Contract defects that void the opt-out |
The fee must buy something Medicare doesn't
On March 31, 2004, the HHS Office of Inspector General issued an alert warning that physicians who accept assignment may not charge Medicare patients extra for services Medicare already covers. The alert described a physician who charged a $600 annual contract for services including care coordination and a comprehensive assessment, services Medicare reimburses.3,
A 2017 legal analysis reported a 2007 settlement in which a physician paid $106,600 after charging annual fees that covered Medicare-covered services such as comprehensive physicals and referral coordination. The same analysis notes concierge physicians may charge for non-covered services and amenities, and that physicians unsure of their structure can request an advisory opinion from HHS.6
Generally safer to include in the fee (confirm with counsel)
- Services Medicare does not cover, such as certain screenings without coverage
- Amenities: extended access, private waiting areas, travel coordination
- Wellness programming not billed to Medicare
Red flags
- Describing the fee as paying for an annual physical Medicare covers
- Bundling care coordination Medicare reimburses
- Conditioning covered care on paying the fee
Read your membership agreement as an auditor would. For each item the fee is said to buy, ask: "Does Medicare pay for this when I bill it?" If yes, it does not belong in the fee description. Have counsel review the final wording.
The opt-out path, step by step
File an opt-out affidavit with every Medicare Administrative Contractor where you would otherwise bill, declaring you will see Medicare beneficiaries only through private contracts.5
Before any service, each Medicare patient signs a contract that states they accept full financial responsibility, will not submit claims, may see other physicians, and that supplemental insurance likely won't pay. Keep contracts for the full period.5
The opt-out lasts two years and renews automatically.4
You may treat a Medicare patient without a contract in an emergency or urgent situation, but must bill Medicare and stay within the limiting charge.5
Send a signed written request so the contractor receives it at least 30 days before the period ends. Requests more than 90 days early are returned. Cancelling does not re-enroll you.4
Failing to meet opt-out requirements can void the opt-out and the private contracts, require billing Medicare again, and prevent a new opt-out until the current term ends.5
Concierge physicians split on Medicare; DPC physicians, a different model, mostly opt out
CMT has asked physicians about Medicare in open online polls since at least 2015, and asked patients what they want in the CMT Patient Study. The samples are small and self-selected, so treat the numbers as directional. The pattern is still useful, because it matches what the rules predict.
These are CMT reader polls, not a scientific survey. Respondents were not verified, chose their own model label and may not represent all physicians. Results are labeled Industry Research (company-reported, not peer-reviewed). Use them for direction and discussion, not as national estimates. Full method in the Methods section below.
These figures describe direct primary care (DPC), not concierge medicine. DPC usually operates outside insurance billing at lower monthly fees. They are shown here, separately, for context only and should not be read as concierge data.
The two models answer differently, as the definitions in Part 1 predict. Concierge practices commonly keep billing insurance, including Medicare, while DPC practices typically operate outside insurance billing.9 That is also why the same membership-fee rules do not apply to both models in the same way.
Concierge answers by year
| CMT concierge poll | Participate in Medicare | Formally opted out | Bill some insurance | Other | Votes |
|---|---|---|---|---|---|
| 2018 poll7 | 14 (35.9%) | 18 (46.2%) | 5 (12.8%) | 2 (5.1%) | 39 |
| 2019 to 2020 poll | 23 (60.5%) | 8 (21.1%) | 7 (18.4%) | Not offered | 38 |
With fewer than 40 votes each, the shift between the two polls is within the range that chance alone could produce. CMT does not report it as a trend.
Two findings that signal confusion
Opting out is what allows a physician to treat Medicare beneficiaries for covered services through private contracts.5 A physician who neither bills Medicare nor has opted out, and who sees Medicare patients for covered services, should review that arrangement with a healthcare attorney. The poll cannot tell us whether any respondent was in that situation; it shows that the question deserves attention.
How many members are on Medicare?
A separate CMT poll of 97 self-identified concierge offices (through February 2020) found 48.5% cash only, 32.0% accepting Medicare and some insurance, 12.4% accepting insurance but not Medicare, and 7.2% accepting Medicare but no HMO or PPO plans.12 Some “cash only” respondents may run DPC-style practices under a concierge label, which is one more reason CMT now reports the two models separately. An earlier 2015 to 2016 poll with 29 votes is not reported as percentages under CMT's rules.
What patients say they want
43% of patients in the CMT Patient Study said insurance or Medicare compatibility is highly important. Coverage Keepers, the oldest-skewing segment, care about it most.
For practices with many Medicare-age members, the choice between participating and opting out is not only a compliance question. It is a question about which patients the practice is built to serve. That is CMT's inference from the segment data, not a finding of the study.
Questions to take to your attorney
Know your panel
What share of members are on Medicare? On Medicare Advantage? Will they accept a private contract?
Audit your fee
List every item the fee covers. Mark each as covered or non-covered by Medicare.
Pick and document
Choose a path with counsel, write it into your membership agreement, and calendar renewal and cancellation dates.
The questions above are prompts for a conversation with a qualified healthcare attorney. They are not a compliance review, and the CMT figures in Part 4 should not be used to judge any individual practice.
Know the line
Fees pay for what Medicare doesn't. Everything else follows from that.
Write it clearly
Your membership agreement is your first compliance document.
Calendar it
Opt-out renewals and cancellation windows are unforgiving. Put them on the practice calendar.
How this brief was built
CMT reviewed the 2004 OIG alert, a GAO report on concierge care and Medicare, a Medicare Administrative Contractor's opt-out guidance, and law firm analyses. This brief describes the general federal framework only. Rules change, Medicare Advantage plans and state laws add layers, and facts matter. This is not legal advice.
CMT proprietary data used in Part 4
CMT reader polls. Seven open online polls hosted on CrowdSignal between about 2015 and 2021, answered by visitors to CMT and DPC Journal web properties who identified themselves as physicians. Totals range from 22 to 116 votes per poll. Respondents were not verified as physicians, could choose their own model label, and could vote more than once from different devices; CMT reviewed vote totals as displayed and did not remove possible duplicates for this edition. Polls with identical answer options were pooled (two concierge polls, n=77; two DPC polls, n=137); others are reported separately. Under CMT's reporting rules, results from fewer than 30 votes are shown as counts only. Poll results are labeled Industry Research (company-reported, not peer-reviewed and not representative) and should be read as directional.
CMT Patient Study. Responses from 561 patients who answered all four rating questions in CMT's patient questionnaire between 2018 and 2024, grouped into four segments by satisfaction with their current doctor and the importance of insurance or Medicare compatibility (see Brief No. 9). Respondents were self-selected patients engaging with CMT's patient resources, so results describe them, not all patients. Labeled Practice Insight.
Margins of error are shown as if samples were random, for scale only; for self-selected samples the true uncertainty is larger.
How to read the evidence types
Every key finding is labeled by evidence type. Labels describe the type of evidence, not its value. Each type answers different questions. Funding is disclosed on every source.
Randomized trials and systematic reviews.Best for cause and effect.
Large observational studies and government data.Best for trends at scale.
Surveys, smaller studies and expert consensus.Best for real-world experience.
Company-sponsored or company-reported data that is not peer-reviewed.Best for early signals and operating data.
Statutes, regulation and official guidance.Best for what is required.
What we don't know
- Current OIG enforcement priorities for membership practices; no recent public enforcement actions specific to concierge fees were identified for this brief.
- How many concierge physicians are opted out vs. participating nationally; no public count exists, and CMT's polls are not representative.
- Whether respondents who said they do not bill Medicare but have not opted out are treating Medicare patients for covered services, which would raise compliance questions.
- How Medicare Advantage plan contracts treat membership fees, which varies by plan.
How to cite this brief
External review: this brief has not yet been reviewed by an outside expert. When review is complete, the reviewer is credited by name above with any conflicts of interest, and the version number is updated. Reviewers check accuracy and fairness; CMT is responsible for the final content.
Corrections policy: when an error is identified, CMT corrects it in the open and updates the version number above. Send corrections to the editor through conciergemedicinetoday.net.
Related CMT Research Briefs
References
- Physicians Practice. Concierge and direct primary care are booming, but corporatization and access questions are close behind. January 21, 2026. www.physicianspractice.comFunding: not stated (news report)
- U.S. Government Accountability Office. Physician Services: Concierge Care Characteristics and Considerations for Medicare (GAO-05-929). August 2005. www.gao.govFunding: federal (GAO; study required by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003)
- HHS Office of Inspector General. OIG Alert: charging Medicare beneficiaries for services that are covered (assignment violations). March 31, 2004. www.hhs.govFunding: federal (HHS Office of Inspector General publication)
- Noridian Healthcare Solutions (Medicare Administrative Contractor). Opt-out period, renewal, and cancellation. med.noridianmedicare.comFunding: federal (Medicare Administrative Contractor guidance issued under contract with CMS)
- Kalogredis VJ, Parekh S. Opting out of Medicare: legal and compliance implications for physicians and practitioners. Lamb McErlane PC. October 13, 2025. www.lambmcerlane.comFunding: not stated (law firm analysis)
- Farrell Fritz. Concierge medicine: Medicare compliance is still a consideration. September 19, 2017. www.farrellfritz.comFunding: not stated (law firm analysis)
- Concierge Medicine Today, LLC. CMT Physician Polls, 2018 (39 votes) and 2019 to 2020 (38 votes): Does your concierge medicine practice bill or participate with Medicare? Open online polls (CrowdSignal), votes recorded through 2021. Not representative; respondents not verified.Funding: Concierge Medicine Today (self-conducted; no outside funder) CMT original
- Concierge Medicine Today, LLC. DPC Journal Physician Poll, 2018 (115 votes), and DPC Physician Poll, 2019 to 2020 (22 votes): Does your DPC practice bill or participate with Medicare? Open online polls (CrowdSignal), votes recorded through 2021. Not representative; respondents not verified.Funding: Concierge Medicine Today (self-conducted; no outside funder) CMT original
- Johns Hopkins Carey Business School. Fee-based primary care is rapidly rising in U.S., hastening doctor shortages for the public. December 2025. carey.jhu.eduFunding: not stated (university news release)
- Concierge Medicine Today, LLC. Poll: Does your private direct medical practice (DPC and/or concierge) bill Medicare? 116 votes, 2018 to 2021. Open online poll (CrowdSignal). Not representative; respondents not verified.Funding: Concierge Medicine Today (self-conducted; no outside funder) CMT original
- Concierge Medicine Today, LLC. Poll: How many of your private membership medicine patients are Medicare participants? 50 votes, approximately 2015 to 2018. Open online poll (CrowdSignal). Not representative; respondents not verified.Funding: Concierge Medicine Today (self-conducted; no outside funder) CMT original
- Concierge Medicine Today, LLC. Poll: Does your concierge medicine office accept and/or bill insurance and/or Medicare? 97 votes, through February 2020. Open online poll (CrowdSignal). Not representative; respondents not verified.Funding: Concierge Medicine Today (self-conducted; no outside funder) CMT original
- Concierge Medicine Today, LLC. CMT Patient Study: patient segmentation by satisfaction with current doctor and importance of insurance or Medicare compatibility (561 patients answering all four rating questions, 2018 to 2024). CMT Research Brief No. 9. Self-selected respondents. conciergemedicinetoday.netFunding: Concierge Medicine Today (self-conducted; no outside funder) CMT original
Educational and informational only. This CMT Research Brief does not constitute medical, legal, tax, financial, accounting or other professional advice, and it does not create a professional relationship of any kind. Statements about laws, regulations, tax rules and payer policies are general, may not reflect the rules in your state, and can change after publication. Consult a qualified attorney, accountant, tax adviser, compliance professional or licensed clinician before acting on anything here.
Independence. Concierge Medicine Today is an independent publication. It does not accept payment for favorable coverage, and it does not favor one practice model over another. Company names and products are mentioned for context only and are not endorsements. Funding is disclosed for every source in the reference list.
Accuracy. CMT verifies figures against their original or best available sources at the time of publication. Where a figure is an estimate, an inference or a company-reported number, the brief says so. This content is not without possible error or omission.
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