Specialist Access in a DPC Practice, From eConsults to Cash-Pay Specialists

How do DPC patients get specialist care?

A direct primary care membership pays for primary care, so specialist care comes from somewhere else, and a practice has three routes to work with. The physician can ask a specialist a written question through an eConsult, refer the patient to a specialist with a published self-pay price, or refer through the patient's insurance or Medicare. Each route answers a different need, and a practice that sets all three up ahead of time can match the question to the route in the moment. The evidence for eConsults is encouraging but not settled, and we found no study of eConsults inside DPC practices, so this guide says plainly where the data stops.

This guide is written for physicians and owners running a practice. It covers operations and the rules around them, not advice for any individual patient.

What the three routes look like side by side

For a sense of scale across medicine as a whole, the share of US ambulatory visits ending in a referral to another physician rose from 4.8% to 9.3% between 1999 and 2009, according to a national analysis published in 2012. That figure is old and covers all physicians, not DPC.

For DPC specifically, the data is thin. The 2020 Milliman study for the Society of Actuaries took up the claim that DPC lowers specialist use and said its claims data could not consistently separate primary care from specialist office visits, so it could not test that claim. We also searched for a survey on how DPC practices arrange specialist access and found none. The text of the DPC Alliance's State of DPC report, collected in October 2024 and published in July 2026, does not report on it, so nothing here states how common any route is.

How does an eConsult work?

An eConsult is an asynchronous, non-face-to-face exchange between a primary care clinician and a specialist on a secure electronic platform. The physician writes one clear question, attaches the relevant notes, labs and images, and sends it. The specialist reviews the file and writes back with an assessment and a plan, or says the patient needs to be seen. The patient never meets the specialist, and the treating clinician stays responsible for carrying out the advice and telling the patient what comes next.

In practice, a good request has four parts, and each one saves a round of back and forth:

• The specific question, written as one sentence.
• The short history that bears on it, not the whole chart.
• The results and images the specialist will want to see.
• What the physician has tried and what they are considering next.

What the billing codes say about eConsults

A cash practice does not need these codes to run eConsults, but they are the clearest public description of the service, and they matter when a specialist bills a patient's Medicare. CMS began paying separately for interprofessional consultation codes in its 2019 fee schedule. CPT 99451 describes a consulting physician's assessment and written report with 5 or more minutes of consultative time, and CPT 99452 describes the treating physician's referral service at 30 minutes.

CMS requires the patient's consent, which can be verbal and must be noted in the medical record, because Medicare cost sharing applies. Since 2020, one consent obtained at least annually can cover multiple consultations. The Milbank Memorial Fund's report adds that 99451 cannot be billed more than once in a seven-day period for the same patient, or when the eConsult leads to a recommended face-to-face specialist visit within 14 days. North Dakota Medicaid's October 2025 manual words the second limit as a transfer of care or other face-to-face service "within the next 14 days or the next available appointment date of the consultant." The consent rule is current as of our check on November 5, 2026. CMS adopted CPT's own language for these codes in 2018 and we did not have that text, so we could not confirm the 7-day and 14-day limits as current for Medicare; have a biller check the current CPT book. These rules apply to billing Medicare, not to a private arrangement.

We did not find CMS guidance that speaks directly to a specialist billing Medicare for an eConsult requested by an opted-out physician. If a practice has opted out and its Medicare members would be affected, ask the specialist's billing office before relying on this route.

Licensure and privacy

A specialist in another state raises a licensure question. The AMA's licensure brief, citing the Federation of State Medical Boards, says licensure or consultation exceptions for telehealth across state lines exist in 40 states plus DC and Guam, with physician-to-physician consultation among the more common exceptions. The details change by state, so confirm the rule in the state where the patient is located with that state's board.

On privacy, HHS says consulting another provider about a patient counts as treatment under the HIPAA Privacy Rule, so it does not need the patient's written authorization. A platform that handles patient information on the practice's behalf is a separate matter, and for a practice covered by HIPAA it generally falls under HIPAA's business associate definition.

What does the evidence say about eConsults?

The honest summary is that eConsults improve speed to an answer in the studies that measured it, and their effect on referral counts is mixed. The reviews below call the evidence modest, low or very low quality, and none of the individual studies below was run in a membership practice.

An earlier review of 43 studies found positive results on access, acceptability, cost and clinician satisfaction, and noted limited research on morbidity and mortality. The Rikin result is worth a second look for anyone setting this up, because it suggests that simply making eConsults available does not change habits. The practical lesson we take from it, and this is our reading rather than a finding, is that the route gets used when it is easy and already part of how the team handles a referral question.

Two cautions apply when carrying these numbers over to a DPC practice. A membership practice runs on a different schedule and payment model from the settings studied, and no study we found measured what that does to eConsult results. A resolved eConsult also means no visit followed, which the studies report as a utilization result, and that is a different thing from showing better health.

How do you build a cash-pay specialist list?

A cash-pay list is a short working document kept by the practice, with a named contact and a written price for each specialist. We found no national dataset of self-pay specialist prices for DPC members, so this guide gives no price range, and the only prices that count are the ones an office confirms to you.

The national referral analysis found that referral rates from primary care visits grew for cardiovascular, gastrointestinal, orthopedic, dermatologic and ear, nose and throat symptoms, which gives a reasonable first set of specialties to call. A practice's own referral log is the better guide once it exists, because it shows what its own members needed.

What to ask each specialist's office

These questions turn a name into something a front desk can use the same day. They work best in writing, so the answer can sit in the list with the date it was given:

1. What is the self-pay price for a new patient visit and for a follow-up, and what does that price include?
2. What else might be billed on top, such as procedures, imaging, pathology or facility fees?
3. How soon can a new patient be seen?
4. How will the note come back to us, and how quickly?
5. Is the physician enrolled in Medicare, opted out, or not enrolled at all?
6. Would the physician take a short written question from us before a visit?
7. Who is the person to call when something goes sideways?

Each answer goes on the list next to the date it was confirmed, because prices and policies move. Pair this with your cash-price imaging list, since a specialist may ask for a study the patient has not had yet.

Self-pay patients also have a federal right that helps here. Under the No Surprises Act, providers and facilities owe a good faith estimate to uninsured and self-pay patients who schedule at least 3 business days ahead or who ask about cost, as the federal rule spells out. That duty sits with the specialist's office. CMS says the rule does not cover patients enrolled in a federal health care program such as Medicare, Medicaid or TRICARE, even if they do not plan to use that coverage. Your team can simply tell other self-pay members to ask for an estimate, and our good faith estimate guide covers the side of it that applies to your own practice.

Keep money out of the list

The list stays cleanest when no money or perk moves between the practice and the specialist. The federal Anti-Kickback Statute reaches referrals for items and services paid by federal health care programs. State fee-splitting and patient-brokering laws vary, and some can reach cash arrangements too. Florida's patient-brokering statute, for one, is written with no payer limit. Our Anti-Kickback and Stark basics walks through both. Any arrangement beyond a plain list, including a markup on an eConsult or a specialist's fee, deserves a review by a health care attorney first, and it is also worth asking your malpractice carrier how it treats written specialist advice, because we could not verify one general rule on liability.

How do you close the referral loop?

A referral finishes when the report has come back and someone has reviewed it, and a cash visit can make that harder, because no plan or shared system tells you the visit happened. Our referral tracking workflow treats each referral as an open task with three checkpoints, which are sent, scheduled and report received. The same structure works for all three routes with small changes.

• For an eConsult, the checkpoints become question sent, answer received, plan acted on and patient told. If the specialist says the patient needs to be seen, the eConsult converts into a referral and its written answer goes along with it.
• For a cash-pay visit, add the price the patient was quoted and whether the note came back in the time the office promised. That second detail, kept over time, tells you which specialists deserve to stay on the list.
• For an insurance referral, add the plan's referral or authorization step, since that is the piece that stalls without anyone noticing. Outside records have their own habits, and our guide to getting outside records covers them.

One person owning the open list matters more than the tool it lives in. Every open item gets a date when someone will next look at it, and it closes only when the ordering physician has read the result and the patient knows what happens next.

How does insurance fit with specialist access?

Specialist care is the job a member's other coverage is there to do, which is why it helps to talk about it at enrollment. Our guide on what insurance to pair with DPC covers the options in detail, and four points bear directly on specialists.

Deductibles. A self-pay bill reaches the plan only if someone submits it, and whether it then counts toward the deductible is up to the plan's own terms. We did not find a federal rule that requires a plan to credit it, so a member with a real chance of meeting the deductible this year should check before choosing cash.

HSAs. The IRS treats amounts paid to physicians as medical expenses, and HSA funds can pay qualified medical expenses, so a member with an HSA can generally use it for a specialist's bill.

Membership design. IRS Notice 2026-5 describes a qualifying arrangement as care "consisting solely of primary care services provided by primary care practitioners," with the fixed periodic fee as the sole compensation, and it says an arrangement that provides services on condition of membership and bills separately for them does not qualify (Q-11), while services offered outside the arrangement to members and non-members alike and billed separately are compatible (Q-12). Bundling specialist visits into a membership does not fit that wording. The notice does not address eConsults, and we found no IRS guidance on whether a specialist's written opinion, paid by the practice or passed to the member, affects a membership's status, so raise it with a tax adviser before writing it into your agreement. Our HSA rules guide covers the rest, including the fee cap.

The cap on those fees for 2027 is $150 a month for one person and $300 a month for a membership covering more than one person.

Source: IRS Rev. Proc. 2026-24.

Medicare. A specialist's status decides what a Medicare member can do. Physicians who have not opted out must submit claims for covered services to their Medicare patients, under section 1848(g)(4) of the Social Security Act, so a plain cash deal with an enrolled specialist is not a substitute for the claim. A specialist who has opted out can use a private contract, and Medicare will not pay for care under it. The exception in 42 CFR 405.440 is emergency or urgent care for a patient who has not signed one.

If you have opted out yourself, your Medicare members can still get covered specialist care on your referral, because 42 CFR 405.425 lets an opted-out physician who is not excluded or revoked order and refer for Medicare-covered services, as long as they are not paid, directly or indirectly, for what they order, prescribe or refer, except as 42 CFR 405.440 allows.

Setting it up over a few weeks

None of this needs to be finished before opening, and it can grow alongside the rest of your launch plan. A workable order looks like this:

1. Write a one-page explanation for members of what the membership covers, what it does not, and how specialist care works. Put the same wording in your member agreement after your attorney has read it.
2. Pull your referral log, or if you are new, start with the specialties named above, and call offices with the seven questions.
3. Pick one eConsult path, whether a platform or a specialist colleague willing to work in writing, then settle consent, licensure, any business associate agreement and how any cost is handled.
4. Set up the open list with an owner and a review rhythm, and add a line for the route chosen on each referral.
5. Review the list on a set schedule and remove anyone whose notes do not come back.

The tools matter more here than they should. The eConsult sits in one inbox, the note arrives by fax, the patient texts about the appointment, and the task lives somewhere else entirely, and those tools were never built to talk to each other. Tabflows is a dedicated tech team that connects the tools a clinic already uses, like the EHR, billing and messaging, so follow-ups, tasks and patient context stay in one place and an open referral stays visible until it closes.