capitation 101 access training & development introduction form of prepayment capitated...
TRANSCRIPT
Capitation 101
Access Training & Development
Introduction
Form of prepayment
Capitated contracts are always HMOs
Providers accept financial risk
Capitation Defined
Per capita, Latin meaning “by head”
HMO pays providers
Provider paid per member per month (PMPM)
Players & Roles
Primary Care Physician (PCP)
Primary Medical Group (PMG)
Independent Practice Associations (IPA)
Managed Service Organization (MSO)
PMG/IPA
PMGs: Primary care and specialists,
may have multiple locations
IPAs: Independent physicians who
associate for contracting purposes
A PMG or IPA may hire an MSO
MSO Managed Service Organization
Acts as business office for PMG/IPA
Provides
UR
Authorization
Claims processing
Contract management
Does NOT provide member enrollment
Effects of Capitation
Predictable cash flow
Providers paid PMPM Regardless of services provided Considered PAID IN FULL
Profit or Loss is based on services used
Healthy patients = Profit
Sick patients = Loss
Authorization & Billing
PCP authorization required
Where to bill depends on:Type of capitated contract
Shared Risk Full Risk
Type of service provided
What Is Risk ?
Providing healthcare coverage at a set price,
regardless of the services needed !
Risk Comparison
Commercial/PPO Controls risk with lifetime maximums
HMO No lifetime maximums
Capitation Risk is spread between HMO and
healthcare providers
Shared Risk/Full Risk HMO
Shared Full
Risk Risk
PMG Hospital
Risk Pools
A bonus/incentive fund For Full Risk capitated contracts
Split between hospital and PMGBased on performance goals
Millions of $$$$$
Risk insurance/Reinsurance
Hospital buys risk insurance
Protects hospital from catastrophic loss
Remember, we’ve already been paid !!
SummaryAll capitated contracts are HMOs, but not all
HMOs are capitated
Per member per month (PMPM)
Shared risk between HMO and PMG
Full risk between HMO, PMG, and contracted hospital
Authorizations required
Any Questions ?