Concierge and Direct Primary Care Billing Services
Concierge and direct primary care practices are paid mostly by patients, not insurers. Members pay a monthly or annual fee in return for access, longer visits and care coordination. That model changes what billing means. Much of the work is membership payments, not claims.
Still, many practices have billing needs. Some bill insurance for certain services, some serve Medicare patients, and some run hybrid models. Each needs clear rules on what the fee covers and what is billed separately. Westmont Revenue Partners connects concierge and direct primary care practices with vetted billing experts who understand these models, so that membership and insurance billing stay separate and compliant.
Who this is for
- Concierge physicians who charge a membership fee
- Direct primary care practices that do not bill insurance
- Hybrid practices that charge a fee and also bill insurance
- Practices converting from traditional to membership models
- Practices serving Medicare patients under private contracts
What gets billed
- Monthly or annual membership fees
- Services outside the membership, such as procedures
- Insurance claims for covered services in hybrid models
- Lab and imaging referred to outside vendors
- In-office tests and injections
- Vaccines
- Medicare-covered services for patients who are not under a private contract
- Patient statements and payment plans
- Employer-sponsored membership invoices
Commonly billed codes
| Code | Type | What it covers |
|---|---|---|
| 99203 | CPT | New patient office visit, low level |
| 99204 | CPT | New patient office visit, moderate level |
| 99213 | CPT | Established patient visit, low level |
| 99214 | CPT | Established patient visit, moderate level |
| 99215 | CPT | Established patient visit, high level |
| G2211 | HCPCS | Add-on for ongoing, longitudinal care in some office visits |
| G0439 | HCPCS | Medicare subsequent annual wellness visit |
| 99490 | CPT | Monthly chronic care management by clinical staff |
| 99396 | CPT | Preventive visit, established patient, ages 40 to 64 |
| 36415 | CPT | Routine blood draw by venipuncture |
| 81002 | CPT | Urine dipstick test, non-automated, without microscopy |
| Z00.00 | ICD-10-CM | Routine adult health exam, no abnormal findings |
Note
Codes are examples for orientation, not a complete list, and do not guarantee coverage or payment. Always check current code sets and payer policy.
Billing challenges in concierge and direct primary care
Separating membership from covered services. A fee that covers services insurers also pay for can raise concerns. Billers help practices define what the membership covers and avoid charging both for the same service.
Medicare rules. Medicare patients generally cannot be charged a fee for services Medicare covers unless an opt-out and private contract are in place. Billers review the setup with legal counsel and keep records.
Hybrid billing models. Practices that bill some insurers need clean separation of fee-based and claim-based work. Billers set up workflows so each patient and service is tracked correctly.
Membership payment processing. Recurring payments need clear terms, failed payment handling and refund policies. Billers manage statements and follow-up.
Health savings account rules. Federal law changed in 2026 to allow some direct primary care fees to be paid from health savings accounts, within limits. Billers help practices describe fees clearly, while patients check their own plan and tax advice.
State insurance regulation. Some states treat membership fees differently, and some have DPC laws. Billers keep a state reference and flag where legal review is needed.
Employer contracts. Employer-paid memberships need invoices and agreements. Billers track contract terms and renewal dates.
How Westmont can help
- Matching you with vetted billing experts who understand membership and hybrid models
- Revenue cycle support for the claims you do send
- Payment processing and statement workflows for membership fees
- Denial management for the insurance side of hybrid practices
- Credentialing and enrollment help where needed
Frequently asked questions
Do direct primary care practices bill insurance?
Most do not. Patients pay a periodic fee for access and services. Some practices still bill insurers for certain services, and some bill none. Others use a hybrid model. A billing expert can help you pick and set up the model that fits your practice and state law.
What is the difference between concierge and direct primary care?
Concierge practices usually charge a membership fee and may still bill insurance for covered services. Direct primary care generally charges a flat fee and often does not bill insurance at all. The terms are not used the same way everywhere, so define yours clearly in patient agreements.
Can a concierge practice treat Medicare patients?
Yes, but the rules matter. A practice may accept Medicare and charge a fee for extra, non-covered services, or a physician may opt out of Medicare and use private contracts. Rules are specific, so get legal advice and check current Medicare guidance.
Can patients use HSA funds for direct primary care?
Recent federal law changes allow some direct primary care arrangements to work with health savings accounts, within limits. Rules are detailed and can change. Patients should check with their plan administrator or tax adviser, and practices should avoid giving tax advice.
Do concierge practices still need a billing company?
Many still do for insurance claims, patient statements, payment processing and compliance. The need depends on your model. Westmont can connect you with vetted billing experts who understand membership practices so you can decide what support you need. Some practices keep a small amount of help for claims and payments, and handle membership billing in house.
Related billing services
See what simpler billing looks like
Tell us about your practice and we will connect you with vetted billing experts. Contact Westmont for a quote.
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