Compliance · Medicare & Medicaid
Medicare & Medicaid — the rules we follow, on the record.
Conceptual Health® clinics serve Medicare and state Medicaid beneficiaries only in states where the clinic is an enrolled, participating provider with the program. We bill at the published fee schedule, we collect cost-sharing per CMS rules, and we apply a beneficiary-inducement carve-out to our HCR/HCC rewards program. This page exists so a CMS auditor, an OIG investigator, a state Medicaid integrity unit, or a beneficiary's family attorney can verify our posture without picking up the phone.
1 · Operating principles
Four rules. No exceptions.
1. No routine cost-share waiver. Cost-share waivers are case-by-case, documented in writing, supported by a financial-need assessment, and consistent with OIG guidance (Special Fraud Alert, 1991).
2. No rewards to induce referrals. HCR and HCC are not paid to a federal beneficiary to induce them to choose a particular provider, to receive a federally reimbursable service, or to refer another beneficiary. Permitted-action codes are listed below.
3. Bill only the program we are enrolled in. If a clinic is not enrolled with Medicare or Medicaid in a given state, the patient is served self-pay at our nominal posted rate or referred to an in-program provider.
4. Every referral is care-driven, never paid. No employee, contractor, or affiliated clinician is compensated based on referral volume or value for federally reimbursable services.
2 · Provider enrollment
State by state, what is and isn't covered.
| State | Clinics | Medicare | Medicaid |
|---|---|---|---|
| Florida | Destin, Niceville, Crestview | Enrolled | Enrolled |
| Alabama | Dothan, Mobile (pilot) | Enrolled | Pending |
| Georgia | Savannah, Atlanta (pilot) | Enrolled | Pending |
| Texas | Houston, Austin (pilot) | Enrolled | Pending |
| All other states | No participating clinic | Not enrolled | Not enrolled |
Posture as of May 2026. PTAN, NPI, and state-Medicaid identifiers are not published on the open web to reduce identity-impersonation risk; they are available under NDA to CMS, OIG, state Medicaid integrity units, and state insurance commissioners via the regulator portal.
3 · Cost-share & financial-hardship policy
Standard. And the documented exception.
Standard. We collect the published copay, coinsurance, and deductible per CMS and state rules at time of service. For Qualified Medicare Beneficiary (QMB) dual-eligibles we apply the dual-eligible rules and do not balance-bill. A statement of charges is provided at end of visit; a posted fee schedule is available on request.
Hardship exception. A waiver may be granted on a case-by-case basis where (a) a written financial-need assessment is in the file, (b) the waiver is not advertised, and (c) the claim adjustment does not misrepresent cost. The intake form on file captures household income and dependents; the decision is signed by the clinic's financial counselor; the assessment is re-evaluated annually with no automatic renewal. Reference: OIG Special Fraud Alert (1991, updated); 42 CFR §1003.110.
4 · HCR/HCC for Medicare & Medicaid beneficiaries
Permitted actions. And the categorical exclusions.
| Action | Permitted? | Rationale |
|---|---|---|
| Daily Orb check-in (voice tone + vitals snapshot) | Yes | Not federally reimbursable. Nominal value < $25/visit and $75/year aggregate. |
| Annual physical / Welcome-to-Medicare exam | Capped, nominal value | Preventive-care carve-out, 42 CFR §1003.110. Never advertised as payment. |
| On-schedule vaccination | Capped, preventive | Not tied to specific manufacturer or provider. |
| Age-appropriate cancer / preventive screening | Capped, preventive | Screening cannot condition follow-up at a CH clinic. |
| Chronic medication adherence (PDC ≥ 80%) | Capped, nominal value | Promotes access to care, low risk. Same payout regardless of which pharmacy filled the prescription. |
| Wearable streak (7-day, 30-day) | Yes | Not federally reimbursable. |
| Genomics / IRB research consent (one-time) | Yes | IRB-approved honorarium under the human-subjects framework. |
| "Refer a friend" / inviting another patient | No | Direct AKS / Beneficiary-Inducement violation. |
| HCR/HCC applied to Medicare/Medicaid copay | No | Routine cost-share waiver. |
Commercial and self-pay patients have no restrictions on the actions above. All issuance is logged on the Conceptual Chain with a category code, a beneficiary's program-coverage flag (no identifying information), and the OIG exception cited. Retention: 10 years. Produced on subpoena or NDA-gated regulator request.
5 · The actual law
Six statutes that govern this surface.
- Anti-Kickback Statute — 42 U.S.C. §1320a-7b(b). Prohibits remuneration to induce or reward referrals for federal health-care program services.
- Beneficiary Inducement CMP — 42 U.S.C. §1320a-7a(a)(5) & 42 CFR §1003.110. Civil penalty for remuneration likely to influence beneficiary selection, with codified exceptions (preventive-care carve-out, nominal-value).
- Stark Physician Self-Referral Law — 42 U.S.C. §1395nn. Prohibits physician referral to an entity with a financial relationship absent an exception. CH does not pay clinicians on referral volume or value.
- False Claims Act — 31 U.S.C. §§3729–3733. Civil and criminal penalties for false or fraudulent Medicare/Medicaid claims. CH submits at the actual fee-schedule rate.
- OIG Special Fraud Alert — Routine Waiver of Copayments or Deductibles (1991, updated). Routine waiver is presumptively a kickback and/or false claim.
- Medicare Provider Enrollment — 42 CFR Part 424, Subpart P. CMS-855 process; the state-by-state enrollment table above reflects approved status.
6 · Concern, complaint, or report
Five doors. All real.
Conceptual Health — compliance@conceptualhealth.com · 30-day acknowledgement
OIG hotline — oig.hhs.gov/fraud/report-fraud · 1-800-HHS-TIPS
CMS (Medicare) — medicare.gov · 1-800-MEDICARE
State Medicaid — state-specific Medicaid Fraud Control Unit
Whistleblower (qui tam) — 31 U.S.C. §3730 · protected and incentivized; consult counsel or the U.S. Attorney's Office.