The DPC Survey's Lead Author Says Moonlighting Generally Requires Being Opted Into Medicare, and Turning Away Medicare Patients Slows Growth.
A physician who leaves a fee-for-service job for direct primary care can expect 1% to 5% of their old patients to follow. Kenneth Qiu, M.D., calls that the community’s rule of thumb, and it means a new practice can open with a thin panel. Many founders moonlight to carry it, and Qiu says that work generally requires being opted into Medicare.
Qiu is a Richmond-area family physician who opened EuDoc straight out of residency. He also led the Direct Primary Care Alliance’s national “State of Direct Primary Care” survey. In an interview published this week by Medical Economics, he described how founders actually get through year one, and the federal billing rule that shapes it.
The year-one math
Per the Medical Economics summary, physicians starting from scratch often moonlight while their panels grow.
That’s a long runway. Medical Economics reports that DPC physicians in Qiu’s survey “who consider their practices full care for roughly 400 to 700 patients.” A doctor who brings 40 patients and needs 500 has a gap to cover while the panel grows, and Medical Economics reports that moonlighting often covers it.
In the summary’s words, Qiu says that work “generally requires being opted into Medicare,” which means billing Medicare for any Medicare patient the physician sees. Many founders choose not to see those patients at all. Qiu says that slows practice growth and limits access for beneficiaries.
Why the choice is all or nothing
The federal rules explain why there’s no middle setting.
Medicare contractor Noridian’s opt-out page says an opted-out provider must sign private contracts with Medicare patients. It also puts the scope of an opt-out plainly: “Opt-out applies to all Medicare programs nationwide, including Original Medicare and Medicare Advantage. A provider cannot opt out for only certain services, locations, or Medicare programs while participating in others.”
That last clause is the moonlighting problem. Under 42 CFR 405.425(a), once a physician opts out, no payment may be made by Medicare or any Medicare Advantage plan to the physician “or to any entity to which the physician or practitioner reassigns his right to receive payment.” So an employer that bills under the doctor’s reassignment can’t collect from Medicare for that doctor’s services, outside the emergency and urgent care cases covered below.
Staying enrolled has its own limit. DPC Frontier’s guidance frames the safe options as two: “remain in Medicare and do not open your DPC practice to Medicare patients, or opt out of Medicare.” Qiu says many founders take the first one and don’t see Medicare patients at all.
So you might find yourself picking between the shift that covers your mortgage and the 67-year-old who wants to join.
The narrow exceptions
The rules do carve out some room, and the details matter for anyone weighing it.
Section 405.440 lets an opted-out physician treat a Medicare patient for emergency or urgent care without a private contract, provided the patient never had one with that doctor. The physician must submit a claim and can collect no more than the Medicare limiting charge.
DPC Frontier’s page on opted-out moonlighting answers the question of how to moonlight after opting out with “with great difficulty.” It describes what an emergency department or urgent care employer would have to agree to: billing Medicare claims under a special code, routing Medicare patients to the opted-out doctor only when no Medicare-accepting clinician is free, and screening out the doctor’s own DPC members. The simplest setting, it says, is “a pure occupational medicine or correctional medicine setting, where no Medicare, Medicaid, or traditional insurance companies are billed.”
An opted-out physician can still order tests, prescribe and refer for Medicare patients, provided they aren’t paid for it, under 405.425(i).
The timing traps
The calendar adds friction. Under 42 CFR 405.410, a nonparticipating physician may opt out at any time. A participating physician can opt out only at the start of a calendar quarter, with the affidavit filed at least 30 days ahead.
Getting back in is harder. An opt-out runs in two-year periods and renews unless the physician cancels at least 30 days before a period ends, according to 405.445. Early termination is allowed only within 90 days of the first period’s start, and only for a physician who has never opted out before.
That’s why DPC Frontier suggests a staged approach for founders who still need outside work: don’t accept Medicare patients on day one, keep a wait list, and opt out once the practice can stand without the side job.
The Tension the Model Lives Inside
Qiu’s survey found DPC practices in 49 states, and most of the responding practices have a single physician. A third of those have no staff at all. Those are the practices most likely to need a second paycheck in the early months.
The rules put the cost of that paycheck on Medicare patients. For a founder who stays enrolled to keep a Medicare-billing shift, the safe path DPC Frontier describes keeps Medicare patients out of the practice. A founder who opts out early to welcome those patients will find moonlighting difficult, and DPC Frontier’s simplest remaining settings are occupational and correctional medicine. The wait-list workaround is real. It still puts a Medicare patient on a wait list for a practice that would gladly take them today.
Qiu also discussed certificate-of-need laws and counting cash prices toward deductibles with Medical Economics. Neither touches this problem. As long as an opt-out cannot be split by setting, the income that gets a new practice through year one and the Medicare patients it could serve will keep pulling against each other.