Managed Care Capitation
Managed care is becoming a reality in more and more primary care facilities. It is vital to be able to identify which participating managed-care plans are most profitable. MicroMD allows the operator to post capitated charges as well as writing that charge off to the plan at the time of posting.
Setup: In the Cap Menu from the main menu bar, the capitation setup screen appears similar to the screen in the upper right. This sets up a specific payment code for fee-for-service charges that might be billed to this managed care insurance company as well as a code for the capitated procedures that this company has already paid to the practice as a participating provider. Two distinct write- off codes (one for capitated procedures and one for fee-for-service procedures) are also set up
in this screen. The posting account is also indi-cated in the capitation setup screen above.
| Posting: As the following three procedures are posted to the patient’s account, a field (Cap Amt) displays the current amount of applicable capitated charges-less the patient’s co-pay amount. In this example, the charges are listed as capitated procedures with this |  |
| insurance plan. The total for the charges totals $53.00-less the patient’s listed co-pay amount of $10.00-for a Cap Amt value of $43.00. | |
| Within the plan setup (as illustrated below) each capitated procedure is listed under the | |
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Capitation Procs tab. This also displays whether a co-pay applies to this procedure. A message flashes during posting if the procedure just posted should be applied to a patient’s co-pay. By clicking this field value with the mouse and dragging it to the lower posting area of the screen, it is written off to the Capitation Payment Posting Account-1003.0 HEALTH CARE MANAGEMENT PLAN. |
If the operator posts a fee-for-service charge during this same encounter, it has no effect on
the Cap Amt field value and therefore does not change the value of the write off. Instead, it applies this to the patient’s account.
Capitation Reports
Included within the capitation module are several Reports.
Patient Report: This report identifies the managed care plan, the patient by account number and name, the patient’s address, city, state and zip code are also displayed. The patient’s
co-pay amount is also displayed as well as whether the insurance coverage is primary, secondary, or tertiary.
Summary Report: This report can be produced for any period of service dates and for any
or all managed care plans. It can be printed for any provider and for any location. When selecting all groups, providers or locations, it can be printed to group according to plan, provider, or location. It tracks the number of patients seen, the number of encounters and visits, and the total of patient payments. It also tracks and compares the charges, payments, and write-offs for both capitated charges as well as fee-for- service charges. This is particularly helpful in year-end reviewing to determine which managed care plans warrant continued participation. A line showing the Fee For Service Equivalent Charges computes what
would have been realized if these charges were posted as fee-for-service instead of capitation.
