Concierge medicine, direct primary care, and cash-pay are not the same model. They share a direction: reducing or removing insurance from the patient relationship. But each one creates a different billing workflow, a different set of payer obligations, and a different set of operational problems when something goes wrong.

The short version: concierge practices typically charge a membership fee and still bill insurance for covered services. DPC practices charge a membership fee and do not bill insurance for primary care services. Cash-pay practices do not use memberships or insurance and collect from the patient at the time of service. Hybrid practices mix elements of two or more of these models.

Each model has billing work. It is different work, but it does not disappear. A practice that moves away from insurance billing often gains membership tracking, superbill generation, patient-balance communication, and payer-boundary questions that did not exist before. A practice that keeps insurance alongside a membership fee has to keep the two revenue streams operationally separate.

This guide is written for practice owners and administrators evaluating or already running one of these models. It is a billing operations guide, not legal or tax advice. Practices should confirm regulatory, compliance, and tax treatment details with counsel and their accountant.

Three models, three billing realities

Concierge medicine

In a concierge or retainer practice, patients pay an annual or monthly membership fee for enhanced access, longer visits, smaller panels, and direct communication with the physician. The AMA Code of Medical Ethics addresses retainer practices and notes that physicians who enter retainer contracts should uphold ethical obligations around access, quality, and continuity.

The key billing distinction: most concierge practices still bill insurance for covered medical services. The membership fee covers access and availability. The insurance claim covers the clinical service. A concierge practice that accepts insurance still has claim submission, denial follow-up, payment posting, ERA reconciliation, patient-balance communication, and AR management. It also has a separate membership revenue stream that insurance does not touch.

Direct primary care

The AAFP describes direct primary care as a model in which patients pay a periodic fee, usually monthly, for a defined set of primary care services. The practice does not bill insurance or other third-party payers on a fee-for-service basis for those services.

The billing distinction: DPC removes insurance billing for primary care services included in the membership agreement. But it does not remove all billing. Patients may still have insurance for specialist referrals, imaging, labs sent to outside facilities, hospital services, and non-primary-care needs. The practice may still generate superbills, coordinate referrals, or handle patient questions about what their insurance covers outside the DPC agreement.

Cash-pay

A cash-pay practice collects payment directly from the patient for each service, without a membership agreement and without billing insurance. Patients may or may not have insurance. If they do, the practice may provide a superbill so the patient can submit to their insurer for possible reimbursement.

The billing distinction: no claim submission, no payer follow-up, no ERA posting. But the practice still needs patient statements, payment collection, pricing transparency, superbill accuracy, and a clear policy for what happens when a patient asks the practice to bill insurance.

Why removing insurance does not mean removing billing

A common assumption is that moving to concierge, DPC, or cash-pay simplifies billing to the point where it barely needs management. That is true for some workflows and false for others.

What goes away or shrinks:

  • Claim submission to commercial or government payers.
  • Denial follow-up.
  • ERA reconciliation.
  • Payer-specific coding and modifier rules.
  • Authorization and referral management (for covered DPC/cash-pay services).
  • Payer contract negotiation.

What stays or grows:

  • Membership fee tracking, renewals, and failed-payment follow-up.
  • Patient statements for services outside the membership agreement.
  • Superbill generation for patients who want to submit to their insurer.
  • Transparent pricing and good-faith estimates.
  • Patient-balance communication for services the membership does not cover.
  • Financial policy documentation.
  • Revenue reporting that separates membership income from service-level collections.
  • Tax and accounting treatment of membership revenue versus fee-for-service revenue.

The net billing burden may be lower, but it is not zero, and the workflow is different enough that the practice cannot simply use its old insurance-billing process with fewer payers.

The hybrid model is the most common and the most complex

Most practices that adopt concierge or DPC elements do not move entirely to one model overnight. They run a hybrid: some patients pay a membership fee, some do not. Some services are billed to insurance, some are not. Some providers in the group may operate under different arrangements.

That hybrid state is where billing complexity concentrates.

In a hybrid concierge practice, the membership fee and the insurance-billed service need to be clearly separated. The membership covers access, availability, communication, and enhanced-visit time. The insurance claim covers the clinical encounter, procedure, or service that has a CPT code, diagnosis, and payer. If the practice conflates the two, the result can be double-billing risk, patient confusion, or payer audit exposure.

In a hybrid DPC practice, the membership agreement may cover a defined set of primary care services, but the practice may also furnish services outside that scope. If a DPC practice orders a lab panel included in the membership, that is handled differently than if the patient needs an MRI or a specialist referral that goes through insurance. Staff need to know which services are inside the agreement and which are outside.

In any hybrid model, the front desk, billing team, EHR, and patient communication all need to reflect the distinction. If the practice cannot tell, at the point of service, whether a specific encounter is membership-covered, insurance-billed, or patient-pay, the downstream billing will be messy.

Membership fees are not billable to insurance

This is the most important billing boundary in concierge and DPC models.

The membership fee is a direct arrangement between the patient and the practice. It is not a covered medical service. It should not appear on a claim. It should not be coded as a procedure. It should not be submitted to a payer.

For the practice, that means:

  • Membership revenue needs its own tracking, separate from insurance collections.
  • Membership invoices should not look like medical bills or EOBs.
  • Failed membership payments need a follow-up process that is separate from patient-balance collections.
  • The membership agreement should clearly state what is included and what is not.
  • The EHR should not generate claims for services that are covered by the membership fee.

For patients, the distinction matters because some may expect to use HSA or FSA funds for membership fees. Whether a DPC membership qualifies for HSA use depends on how the arrangement is structured and current IRS guidance. Practices should not make blanket promises about tax treatment without directing patients to their own tax advisor.

What insurance billing still looks like in a concierge practice

A concierge practice that accepts insurance is still running a revenue cycle for covered services. The membership fee changes the patient relationship, but it does not change how a claim moves through the system.

That means the practice still needs:

  • Accurate insurance capture and eligibility verification.
  • Clean charge entry with appropriate codes, modifiers, and diagnosis support.
  • Timely claim submission through a clearinghouse.
  • Rejection correction and denial follow-up.
  • ERA and payment posting.
  • Underpayment review against contracted rates.
  • AR management by age and payer.
  • Patient-balance communication for copays, deductibles, and coinsurance.
  • Monthly reporting the owner can use.

The difference is that the concierge panel is usually smaller, which can reduce volume. But smaller panels do not automatically reduce complexity. A 300-patient concierge panel with multiple payers, Medicare patients, specialist referrals, and procedure codes can still generate meaningful billing work.

If the practice assumes the membership model eliminates the need for billing oversight, underpayments, denials, and AR problems can accumulate quietly because nobody is watching.

DPC and the insurance boundary

A DPC practice that does not bill insurance for primary care services still interacts with the insurance system in several ways.

Labs and imaging

If the DPC membership includes in-office labs or basic diagnostics, those are handled inside the agreement. But if the patient needs labs sent to an outside reference lab, imaging at a radiology center, or pathology services, those facilities will often bill the patient’s insurance. The DPC practice may need to provide orders, referrals, or coordination that touches the insurance system even though the practice itself is not submitting claims.

Specialist referrals

When a DPC patient needs a specialist, the specialist will typically bill the patient’s insurance. The DPC practice may need to provide referral documentation, prior authorization support, or clinical summaries that help the specialist’s claim process correctly.

Superbills

Some DPC patients ask whether they can submit a superbill to their insurer for reimbursement of services received at the DPC practice. The answer depends on the patient’s plan, the service, and how the DPC agreement is structured. The practice should have a clear policy: does it provide superbills, and if so, what codes and diagnoses does it include? An inaccurate superbill can create problems for the patient and the practice.

Non-primary-care services

If a DPC practice furnishes services outside the scope of the membership agreement, such as procedures, urgent care, or services the agreement explicitly excludes, the billing pathway for those services needs to be defined. Are they billed to insurance? Collected as cash-pay? Included at an additional fee?

The cleaner the membership agreement defines the boundary, the easier it is for the billing workflow to follow.

Cash-pay and pricing transparency

A cash-pay practice that does not bill insurance at all has the simplest payer workflow but the most direct patient-financial relationship.

The billing work in a cash-pay model includes:

  • Setting and publishing prices for each service.
  • Collecting payment at the time of service.
  • Generating accurate superbills for patients who request them.
  • Providing good-faith estimates when required.
  • Handling patient disputes about pricing or unexpected charges.
  • Tracking revenue by service, provider, and period.
  • Managing refunds or credits when services change.

The No Surprises Act and state-level pricing transparency requirements may apply depending on the practice’s structure and patient population. Practices should confirm their obligations rather than assuming that “no insurance” means “no compliance requirements.”

Medicare considerations

Medicare adds specific complexity to all three models.

Concierge and Medicare

A concierge practice that accepts Medicare must follow Medicare billing rules for covered services furnished to Medicare beneficiaries. The membership fee cannot be charged for services that Medicare covers. The practice must be careful that the membership does not create a situation where Medicare patients are being charged separately for services that should be billed to and paid by Medicare.

CMS has stated that a physician who has not opted out of Medicare cannot charge a Medicare beneficiary for a Medicare-covered service outside of the Medicare payment system, except in specific circumstances. That means a concierge practice billing Medicare needs to draw a clear line between what the membership covers (access, availability, enhanced communication) and what Medicare covers (the clinical service).

DPC and Medicare

A DPC practice that does not bill Medicare has a fundamental question: is the physician enrolled in Medicare, opted out of Medicare, or not enrolled?

If the physician is enrolled in Medicare and has not opted out, billing rules still apply when furnishing Medicare-covered services to Medicare beneficiaries. Simply choosing not to submit a claim does not automatically exempt the practice from Medicare’s rules about what can be charged.

If the physician has opted out of Medicare, the opt-out affidavit and private-contract requirements apply. That pathway is covered in detail in Medicare Opt-Out for Private Practices: The Complete Guide.

If the physician was never enrolled in Medicare and does not see Medicare beneficiaries for covered services, Medicare rules may not apply. But the practice should confirm rather than assume, especially if any patients are Medicare-eligible.

Medicaid

Some DPC advocates have explored using DPC models for Medicaid populations. At the federal level, legislation has been introduced to clarify how states could work with CMS to provide Medicaid beneficiaries access to DPC arrangements. But the regulatory and billing landscape for DPC and Medicaid is still evolving. Practices should not assume Medicaid patients can be moved into a DPC membership without confirming the legal and billing requirements in their state.

State DPC legislation

As of 2025, more than 30 states have enacted laws addressing direct primary care arrangements. The DPC Frontier tracks state-by-state legislation, and McDermott Will & Emery has published a 50-state survey of DPC arrangement laws.

Most of these laws do one primary thing: they clarify that a DPC agreement is not an insurance product and is not regulated as insurance. That matters for the practice’s regulatory status, but it does not change the billing rules that apply when the practice interacts with insurance, Medicare, or Medicaid for services outside the DPC agreement.

For billing, the practical takeaway is:

  • A DPC-enabling statute does not exempt the practice from Medicare rules.
  • A DPC-enabling statute does not automatically make the membership fee HSA-eligible.
  • A DPC-enabling statute does not remove compliance obligations for services billed to insurance.
  • A DPC-enabling statute does clarify that the state insurance commissioner generally does not regulate the DPC agreement itself.

Practices should check their state’s specific DPC statute and confirm how it interacts with their billing model, especially if the practice also furnishes services outside the DPC agreement.

EHR configuration for hybrid models

The EHR is where concierge, DPC, and hybrid billing either works or breaks.

Most EHR and practice-management systems are built around insurance billing. They expect a payer, a claim, a code, and a payment. When a practice introduces a membership model, the EHR needs to distinguish between:

  • Encounters covered by the membership agreement (no claim generated).
  • Encounters billed to insurance (normal claim workflow).
  • Encounters billed directly to the patient (cash-pay or out-of-scope service).
  • Membership fee collection (separate from clinical billing).
  • Superbill generation (patient-facing document, not a submitted claim).

If the EHR cannot make those distinctions, staff will rely on manual overrides, which break at scale.

Useful EHR controls for hybrid practices include:

  • A membership status flag on the patient record.
  • A billing pathway selector at the encounter level.
  • Claim suppression rules for membership-covered services.
  • Superbill templates that reflect the practice’s actual service codes.
  • Membership fee tracking that is visible but separate from clinical AR.
  • Reporting that separates membership revenue from insurance revenue from patient-pay revenue.

If the EHR does not support these distinctions natively, the practice may need workarounds, templates, or external tracking. The important thing is that the distinction exists somewhere the billing team can see it before a claim is generated or a patient statement is sent.

Common billing mistakes in these models

Billing insurance for membership-covered services

If a service is included in the membership agreement, it should not also be billed to insurance. Doing both is a compliance risk. The practice needs to decide, per service, which revenue pathway applies.

Not billing insurance for services that should be billed

The reverse problem: a concierge practice stops submitting claims for services that insurance should cover, either because staff assume the membership handles everything or because the workflow is unclear. The practice leaves money on the table, and the patient may lose insurance credit toward their deductible.

Inconsistent superbills

A cash-pay or DPC practice that provides superbills inconsistently, with wrong codes, missing diagnoses, or outdated fee schedules, creates problems for patients and potential audit exposure for the practice.

No clear membership agreement

If the agreement does not clearly define which services are included and which are not, every ambiguous service becomes a billing dispute. The agreement is a billing document, not just a marketing document.

Ignoring Medicare rules

Assuming that a DPC or cash-pay model exempts the practice from Medicare obligations when the physician is still enrolled in Medicare. This is the single most common regulatory mistake in these models.

Treating all patients identically

In a hybrid model, not all patients have the same billing pathway. The EHR, front desk, and billing team must be able to distinguish membership patients from non-membership patients, and insured services from membership-covered or cash-pay services.

No failed-payment follow-up for memberships

Membership revenue requires its own collections discipline. If a patient’s credit card fails and nobody follows up, the practice loses recurring revenue without a denial notice or claim rejection to trigger action.

When this matters for billing

Concierge, DPC, and cash-pay models all change the billing workflow. The question is whether the practice has updated its billing operations to match the model it is running.

For a practice evaluating these models, the core billing questions are:

  1. Which services will be covered by the membership fee, and which will be billed to insurance or collected from the patient?
  2. How will the EHR distinguish membership-covered encounters from insurance-billed encounters?
  3. What is the practice’s Medicare status, and does the billing model comply with Medicare rules for enrolled, non-participating, or opted-out providers?
  4. Will the practice provide superbills, and if so, what will they include?
  5. How will membership revenue be tracked, invoiced, and reconciled separately from clinical billing?
  6. What happens when a patient’s membership payment fails?
  7. What is the patient communication plan for explaining what the membership covers versus what insurance covers?

If those answers are not clear before the practice launches or scales the model, the billing system will improvise. Improvised billing creates collections gaps, compliance exposure, and patient confusion.

How Neobill can help

Neobill works with concierge, DPC, cash-pay, and hybrid practices where the billing model is not a simple insurance claim factory. For practices with meaningful membership or cash revenue alongside insurance billing, the engagement can be scoped around the insurance-billing work that still needs ownership: claim submission, denial follow-up, underpayment review, AR management, patient-balance communication, and reporting. The free audit reviews the practice’s current mix of membership revenue, insurance billing, and cash collections to identify where the billing workflow matches the model and where it does not. For practices where Medicare opt-out is part of the strategy, see Medicare Opt-Out for Private Practices: The Complete Guide. For practices focused on EHR-level billing, see EHR-Integrated Medical Billing Services: How It Works.