The Routine Exam Model returns healthcare to what it was meant to be: comprehensive, relationship-based, and free from insurance dictates. It has 100+ years of proven demand, dating to before modern health insurance existed, and it remains Medicare compliant today.
The origin of our approach dates back to 1913 when healthcare innovators developed the concept of ongoing ‘routine exams’ focused on prevention rather than waiting for illness. This model evolved further in 1920-1921 as a worker health program that dramatically improved outcomes through regular assessments detached from medical necessity.
This proven approach later became the foundation for executive health programs, which have quietly maintained Medicare compliance through specific statutory exclusions dating back to 1965, further clarified in 1996 and 2006. Our model leverages this same historical and legal foundation while making it accessible to a broader patient population.
The foundation of the Routine Exam Model dates back to 1913 when the Life Extension Institute established an innovative approach to healthcare focused on prevention rather than intervention. By 1921, this model had evolved into structured worker health programs implementing routine exams detached from specific medical necessity.
From the National Industrial Conference Board’s 1921 publication “Health Service in Industry”:
“The medical examination, given at regular intervals, is the keystone of the personal health service.”
This approach formed the basis of what would eventually become “executive health” programs comprehensive preventive care services designed to keep corporate leaders healthy and productive for as long as possible.
When Medicare was established in 1965, the Social Security Act specifically excluded “routine physical checkups” from coverage. This exclusion, further clarified and strengthened in additional federal statutes in 1996 and 2006, creates the legal foundation for our model:
“The following services are excluded from coverage: (a) Routine physical checkups such as: Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury…” — 42 C.F.R. § 411.15(a)(1)
This statutory framework creates the foundation for Medicare-compliant cash healthcare based on routine exams, check-ups, and physicals.
Today, we help healthcare professionals implement this time-tested model in their own practices, allowing them to:
Importantly, none of the three federal statutes excluding routine exams, check-ups, and physicals from Medicare coverage ever defined “routine.” This flexibility is both a strength and a source of confusion.
Healthcare professionals themselves determine if a service is covered by a plan (and therefore not part of “routine” exams) simply by:
Periodic routine follow-up exams throughout the year to monitor progress, adjust recommendations, and provide ongoing health guidance. These are not triggered by medical necessity but are pre-sold as part of the routine care program.
Structured communication pathways between the healthcare professional and patient that support the annual and follow-up routine exam services.
The flexibility to maintain insurance relationships for non-routine services as desired. Unlike many direct care models that require abandoning insurance entirely, the Routine Exam Model allows healthcare professionals bill plans never, some, or more for non-routine services.
| Feature | Routine Exam Model | Other Direct Care Models | Typical DPC |
|---|---|---|---|
| Medicare Compliance | Full compliance without opt-out | Variable compliance approaches | Typically requires Medicare opt-out |
| Marketing Approach | Markets routine exams, check-ups, and physicals, and related communications | Often markets non-compliant services | Markets primary care services and access |
| HSA/HRA/FSA/MSA and Employer Funding | Structured for tax-advantaged funding | Generally doesn’t qualify | Generally doesn’t qualify |
| Insurance Integration | Flexible – can bill insurance as desired | Often maintains insurance billing | Typically abandons insurance |
| Applicable Specialties | Works for any healthcare specialty | Primarily primary care focused | Primarily primary care focused |
| Historical Foundation | Based on 100+ year model with statutory protection | Derivative of executive health | Newer model without specific statutory protection |
The Routine Exam Model is built on explicit statutory exclusions dating back to 1965. This legal framework provides healthcare professionals with confidence that their membership healthcare model is Medicare compliant without requiring opt-out.
| Funding Source | US Market Size (2024) | Key Advantage for Routine Exam Model |
|---|---|---|
| HSA Accounts | $137 billion | Unused funds carry over yearly |
| FSA Accounts | $3.6 billion annual contributions | Increasingly flexible usage rules |
| HRA Arrangements | $2.5 billion | Employer-funded benefits |
| MSA Accounts | Growing opportunity | Self-employed/small business option |
Proper qualification for these funding sources dramatically expands your potential patient base by making your services accessible to those who might otherwise be unable to afford direct care.
Subscription-based model eliminates reimbursement uncertainty and creates stable cash flow
Significant decrease in billing, coding, and collection expenses compared to insurance-based practice
Less documentation and paperwork requirements, allowing reallocation of resources to patient care
Fee structure that adequately compensates for comprehensive preventive care and time spent with patients
Financial model that supports comprehensive patient care rather than treating disease
Our implementation process is methodical and comprehensive, ensuring your practice transformation is both successful and compliant
No. Unlike many DPC models, our approach maintains full Medicare compliance without requiring opt-out. This allows you to continue seeing Medicare patients while offering cash services for routine exams that aren’t covered by Medicare.
It also lets you keep locum work, which requires staying in Medicare.
Yes. Program patient fees are designed to be qualified medical expenses to enable employer/self-employed/HSA/HRA/FSA/MSA funding.
Coverage is not determined by the patient’s condition; it is solely determined by what the healthcare professional does or doesn’t do. If you choose not to document and bill a service to insurance, it is not “covered” regardless of the patient’s condition. The healthcare professional, not the patient’s condition, determines coverage.
Your patient buys the year’s annual and follow-up exams before anyone knows what the year will bring, so those exams remain routine even when the patient is sick.
While both are subscription-based approaches, the Routine Exam Model has stronger Medicare compliance foundations through specific statutory exclusions, better qualification for HSA/HRA/FSA/MSA and employer funding, and greater flexibility regarding insurance integration. These advantages create a more sustainable and accessible model than traditional retainer medicine.
All consultations are completely confidential with no obligation.
Contact Information:
Jim Eischen
Eischen DPSC LLC
2323 Locust Street
San Diego, CA 92106
619-919-5395
jim@eischendpsc.com
