CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Concierge (retainer/boutique) primary care practice participation and billing

Governs how concierge (retainer/boutique) primary care practices may participate in BCBSRI networks, what fees may be charged to members, and billing/participation requirements for providers.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyConcierge (retainer/boutique) primary care practice participation and billing

Policy CodePolicy N/A

Change TypeRevised — allows concierge providers to participate

Effective Date

Next Review Date

Key ActionProviders must identify themselves as concierge on initial application and existing participating providers must give 90-day written notice before establishing a concierge practice.

SourceLink

POLICY UPDATE CHANGES

BCBSRI will allow concierge practice providers to participate in the plan's provider network if they meet standard credentialing and contracting requirements and follow participation requirements.

90-daywritten notice required

0retainer fees covered

ProhibitedMedicare Advantage charging

Nonerelated policies

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Concierge practice coverage and network participation criteria

Coverage stance and provider requirements for concierge (retainer/boutique) practices.

Retainer/access fees are not covered by BCBSRI and must not be billed to BCBSRI; providers must submit claims for all Covered Health Services and may only collect applicable member copayments, coinsurance, or deductibles as outlined in the member's benefit plan.

Providers must adhere to all requirements of their participating provider agreement and BCBSRI administrative policies; practices will be monitored for compliance and noncompliance may result in termination from the network.

BCBSRI will consider concierge-designated primary care practitioners (Internal Medicine, Family Medicine, Pediatrics) who meet standard BCBSRI credentialing requirements to participate in the network; providers must identify themselves as concierge on initial application.

Existing participating providers who intend to establish a concierge practice must provide 90-day written notice to BCBSRI detailing intent to establish the concierge practice (send notice via email to ProviderRelations@bcbsri.org).

If a provider operates exclusively as a concierge practice, they must refer BCBSRI patients who do not wish to participate to another network provider or refer subscribers to customer service for assistance obtaining a new primary care physician.

If providers offer both concierge and non-concierge services, participation in concierge services must be voluntary for BCBSRI subscribers; non-paying patients must not experience differences in access, quality, responsiveness, or comprehensiveness of care.

Providers who charge supplemental fees must make clear that no payment is required to become or remain a patient (other than ordinary deductibles/copays/coinsurance); office procedures must prevent any misconception that the fee is required for Covered Health Services, and BCBSRI may audit compliance.

BCBSRI reserves the right to identify concierge providers in provider directories and/or remove them at its sole discretion.

Charging Medicare beneficiaries, including Medicare Advantage members, a retainer is a violation of Medicare statutes and regulations unless the physician has formally opted out of Medicare; under no circumstances should Medicare Advantage members be charged a retainer fee.

Billing, Coding & Fee Rules

Coding applicabilitymixed

No codes listed

Retainer fee billing — rules and claims guidance

Billing to BCBSRIRetainer/access fees are not covered by BCBSRI and must not be billed to BCBSRI or applied toward services covered under the member's contract.

Claims submissionClaims for all Covered Health Services must be submitted through normal claim channels; providers may only collect applicable copayments, coinsurance, or deductibles per the member's benefit plan.

Provider agreement complianceProviders must adhere to all requirements of their participating provider agreement and BCBSRI administrative policies; practices will be monitored for compliance.

Scope of feesAccess/retainer fees may cover enhanced services but cannot be applied to reduce member cost-sharing or replace billed Covered Health Services.

EnforcementNoncompliance with billing rules may result in monitoring and actions up to termination per the Physician Agreement and Subscriber Agreement: Billing.

Provider Notification, Identification & Participation Steps

Documentation Required

Provider notification and identification — initial disclosure and 90‑day notice

Providers applying to participate in BCBSRI’s network must disclose on their initial application if they operate as a concierge practice. Providers who are already participating in the BCBSRI network and intend to establish a concierge practice must provide BCBSRI with 90 days’ written notice detailing their intent and whether they will operate exclusively as a concierge practice; the notice should be sent via email to ProviderRelations@bcbsri.org. Providers who operate exclusively as concierge practices must refer BCBSRI patients who do not wish to participate to another network provider or refer subscribers to customer service for assistance obtaining a new PCP. Providers offering both concierge and non-concierge services must make participation voluntary for BCBSRI subscribers and must not discriminate against non‑paying patients in access, quality, or comprehensiveness of care. BCBSRI may identify concierge providers in directories or remove them at its sole discretion.

Identify as concierge on initial application to become a participating provider.
Existing participating providers must give 90-day written notice to BCBSRI (email ProviderRelations@bcbsri.org) with intent and whether practice will be exclusive concierge.
Refer non‑participating BCBSRI patients to another network PCP or to customer service if operating exclusively as concierge.
If offering both models, make concierge participation voluntary and do not discriminate against non‑concierge patients.
BCBSRI may label or remove concierge providers from directories at its sole discretion.

Key Terms

Concierge/retainer/boutique practice — definition

DefinitionA concierge/retainer/boutique practice is a primary care model that charges an access fee to patients to provide enhanced services (e.g., 24/7 access, enhanced coordination, personalized plans).

Typical featuresEnhanced services often include direct 24/7 access to the physician, expanded coordination of referrals, extensive clinical work-ups, and personalized wellness plans beyond typical practice offerings.

Panel sizeThese practice models typically reduce patient panels significantly to provide additional services to fewer patients.

BCBSRI stanceBCBSRI does not endorse development of concierge practices and will monitor for access and quality-of-care concerns; policy changes may follow if issues arise.