Thinking About Direct Primary Care? Let’s Talk Risk, Not Just Freedom

THE PROS: What Direct Primary Care Can Eliminate

• No Insurance Claims = No Insurance Billing
  • No need to submit to Medicare, Medicaid, or commercial payers.
  • That means no E/M level justifications, prior authorizations, or clearinghouse rejections.
• Freedom from RVU Pressure
  • You can focus on outcomes and relationships—not production metrics.
• Simplified Coding (Possibly)
  • Since you’re not billing insurers, CPT and ICD-10 codes may become secondary, used primarily for internal tracking or continuity of care.
• Lean Staffing Models
  • Without a billing department managing denials, appeals, and payer audits, you may be able to reduce overhead

THE REALITY CHECK: What You Still Need

• Documentation Still Matters
  • Even if you’re not billing insurers, clear documentation protects you legally, supports continuity, and justifies the care provided.
  • If you ever transition back into a payer model or participate in hybrid arrangements, you’ll be thankful you kept strong records.
  • Documentation is necessary not only for operational and compliance purposes, but also for legal and malpractice protection.
  • Clear and thorough records should always be maintained.
• ICD-10 Codes Are Not Optional for Reporting
  • Labs, imaging, and referrals still rely on diagnosis codes. Poor documentation can delay or block downstream services.
• Compliance Isn’t Canceled
  • You may no longer be subject to payer audits, but you’re not immune to board reviews, malpractice defense, or licensure scrutiny.
  • HIPAA, state-specific Direct Primary Care laws, and IRS guidelines (especially if offering employer plans) still apply.

WHAT TO CONSIDER BEFORE YOU JUMP IN

• Do you have a plan for ongoing clinical documentation training, for yourself and your team?
  • This may involve standard evaluation and management documentation training, which remains relevant even if not required. The key point is this: do not become complacent in your documentation practices.
• Are you maintaining accurate diagnosis tracking for analytics, referrals, and care planning?
  • Stay current with annual ICD-10 updates and ensure your coding practices are specific and accurate. Proper coding is essential to help your patients receive appropriate insurance coverage for testing and advanced services, when applicable.
• Have you considered how this affects credentialing, liability coverage, and regulatory compliance?
  • Verify with your liability carrier whether changes in coverage are needed, review and update your compliance plan policies accordingly, and consult with a practice management expert to assess your credentialing status, it may be worth exploring out-of-network status is allowed rather than full disenrollment.

Direct Primary Care may offer some operational simplifications, but it doesn’t eliminate your need for structure, documentation integrity, and regulatory awareness.

In fact, if not implemented thoughtfully, the model can create blind spots that expose you to unnecessary risk.

If you’re considering Direct Primary Care, let’s talk. A conversation now can prevent a problem later, and position you for long-term success, no matter how you deliver care.

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