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Thread: capitation payments

  1. #1

    Post capitation payments

    AAPC: Back to School
    Hello All.

    I recently started billing for a Pediatric group. I am not sure how to handle the capitation payments. Does anyone have any knowledge regarding the billing fee structure for capitation fees?

  2. #2
    Join Date
    Apr 2007
    Concord, NC or Rochester, NY


    Capitation payments are ususally PMPM (per member per month) based on the number of members the group is responsible for. Personally I still want to know whether this or FFS would be the best alternative so it would be beneficial to keep track of the visits in the billing system.

  3. #3
    Join Date
    Apr 2007
    Oakland, CA

    Default Question Regarding Capitation

    Hi there,

    I manage and reconcile capitation paid from the health plans at a large IPA. We receive and reconcile the cap from the plans and in turn pay the physicians capitation for their members.

    Having worked in many differnt practices over the years and having dealt with handling capitation in many different systems I can tell you that I really did not fully appreciate how captitation worked until I started working directly with the plans and reconciling their cap payments.

    Posting cap in your practice management system can be done in a variety of ways. Some choose to post a one lump payment to a "cap account" in their system, some post to the individual member every month (which is tedious especially if you have a large capped population). Some, more advanced systems, have their own methods for handling cap, which is nice.

    But what you REALLY need to do is reconcile your cap payments to your list of members that you show eligible with the capped plan. The easiest way to do this is in Access or Excel. What you want to look for are members that you show as eligible but are NOT in your cap payment. Once you have identified members for which you did not receive cap, send the list to your health plan and request a response and/or payment. I recommend that you do this every month as some plans have a 90 retro limit.

    I hope this helps!


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