WHAT IS DIRECT PAY ? CAN I USE MY HSA ACCOUNT TO PAY FOR THE MONTHLY PREMIUM

YES

DPC is a common acronym with several meanings depending on the context, including Direct Primary Care, a healthcare model where patients pay a flat fee for services;

The Direct Primary Care (DPC) model is a practice and payment model where patients/consumers pay their physician or practice directly in the form of periodic payments for a defined set of primary care services. DPC practices typically charge patients a flat monthly or annual fee, under terms of a contract, in exchange for access to a broad range of primary care and medical administrative services. The DPC practice framework includes any practice model structured around direct contracting with patients/consumers for monthly or annual fees which serve to replace the traditional system of third party insurance coverage for primary care services. Typically, these periodic payments provide patients enhanced services over traditional fee-for-service medicine. Such services may include real time access via advanced communication technology to their personal physician, extended visits, in some cases home-based medical visits, and highly personalized, coordinated, and comprehensive care administration. The AAFP supports the physician and patient choice to, respectively, provide and receive healthcare in any ethical healthcare delivery system model, including the DPC practice-setting.

The DPC contract between a patient and his/her physician provides for regular, recurring monthly revenue to practices which typically replaces traditional fee-for-service billing to third party insurance plan providers. For family physicians, this revenue model can stabilize practice finances, allowing the physician and office staff to focus on the needs of the patient and improving their health outcomes rather than coding and billing. Patients, in turn, benefit from having a DPC practice because the contract fee covers the cost of many primary care services furnished in the DPC practice. This effectively removes any additional financial barriers the patient may encounter in accessing routine care primary care, including preventative, wellness, and chronic care services. Most patients, depending on affordability, still carry insurance for coverage of healthcare services that cannot be provided in the primary care practice setting, such as specialty care and hospitalizations. The model is especially well suited for those patients with high deductible plans where they might normally be paying out of pocket for any primary care services that are not considered preventive.

Ideally, the DPC model is structured to emphasize and prioritize the intrinsic power of the relationship between a patient and his/her family physician to improve health outcomes and lower overall health care costs. The DPC contract fee structure can enable physicians to spend more time with their patients, both in face-to-face visits, and through telephonic or electronic communications mediums should they choose, since they are not bound by insurance reimbursement restrictions. For these reasons, the DPC model is consistent with the American Academy of Family Physicians' (AAFP) advocacy of the advanced primary care functions and a blended payment method of paying family medicine practices. The AAFP provides resources for members tranforming to this model, including CME credit, and will continue to promote and support Direct Primary Care as an innovative advanced practice model. (2013 COD) (September 2024 COD)

DPC practices handle lab tests by providing basic in-house tests for members and arranging external lab work at discounted rates when necessary. In many DPC clinics, blood draws are performed on-site, eliminating the need for a separate lab appointment. For specialized tests, DPC providers often have negotiated rates with national labs and may direct billing to the patient or their insurance, depending on the agreement. 

In-house testing

• Many DPC practices offer common, basic lab tests directly in the clinic.
• This allows for more comprehensive care and can include services like blood draws during a regular visit.
• Results are typically discussed in detail with the patient during the visit. 

External lab tests

• For specialized tests not performed in-house, DPC providers work with external labs.
• They often have negotiated, discounted rates for their members and may handle the billing process.
• Patients may have the option to have the test billed through their insurance, even if the DPC membership does not cover it. 

Patient access to results

• Patients can expect to receive their lab results directly, often through the DPC practice's patient portal or app.
• Many DPC systems allow patients to view their results and communicate with their doctor about them.
• In some states, consumers are also permitted to order some tests directly from a lab without a physician's order. Direct Primary Care (DPC) practices typically handle imaging by contracting with local imaging centers to provide services at a reduced cash price, often resulting in savings of 50–90% for patients. In some cases, a DPC practice may also have its own limited in-office imaging capabilities, such as an X-ray or lab services, which allows them to offer these services directly to members. These practices often leverage their cash-pay model and direct relationships with imaging providers to offer more affordable diagnostic options for their patients, especially when compared to services billed through traditional insurance. 
  How DPC handles imaging
  • Contracts with imaging centers: DPC practices can have direct contracts with local radiology and imaging centers.
  • Reduced cash prices: These contracts often allow DPC patients to pay a significantly lower cash price for services like X-rays or MRIs, with savings of 50–90% compared to traditional insurance costs.
  • In-office imaging: Some DPC practices may perform basic imaging, such as X-rays or lab work, directly in the office.
  • Direct billing: Instead of dealing with insurance companies, the patient pays the DPC practice directly, and the practice handles the payment to the imaging center.
  • Cost transparency: The DPC model makes the cost of imaging services clear and transparent, allowing patients to make informed decisions about their care. 
  Examples of DPC imaging services
  • Chest X-ray: May cost around $45.
  • MRI of the knee: May cost around $300. 
  Why this model is effective
  • Lower costs: The cash-pay model allows practices and patients to bypass the complexities and costs associated with traditional insurance billing.
  • Direct relationships: DPC practices can build strong relationships with local imaging providers, leading to better rates and more streamlined care for patients.
  • Patient-centered care: This approach allows for greater flexibility and cost savings for patients, who can focus on their health needs without the burden of traditional insurance hurdles.
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