Pre-requisite

• Important: It is mandatory to choose the 'Ins. Capitation' Insurance type plan to create capitation-type claims.
• The capitation-type claims should have the 'Ins. Capitation' Insurance type plan as Primary Insurance.
• Whenever a claim has the 'Ins. Capitation' Insurance type plan, Secondary Insurance is not allowed.

Creation of Capitation Claim:

Creation of a Capitation claim from the EMR side

A Capitation claim is created from the EMR side only if

1. The patient has a valid Primary Insurance having an Insurance type of 'Ins. Capitation'.
2. Assign a valid Primary Insurance having an Insurance type of 'Ins. Capitation' from the Patient Insurance Screen.

Default Info on the Claims >> Edit Screen

When a Capitation claim is created,

• The word 'CAPITATION' is displayed in red and bold font when the claim is saved.
• The 'Send' button is disabled.
• The 'Void' button is disabled.

For creating an Employer claim from the Claims >> New screen directly:

Create a claim where the patient has a valid primary insurance and its insurance type should necessarily be 'Ins. Capitation'. When this newly created claim is saved, the word 'CAPITATION' is displayed in red and bold font.

Other important aspects about the Capitation Claim

• • Capitation claims are sent to the Insurances in the normal way. Insurances typically send a Paper EOB.
  • 'I' button: The Attending Provider name is displayed in a disabled Edit Control.
  • 'I' button: If Capitation was applicable and the property 'billing.capitation.outsideproviders' is set to 'Y', then the 'Search' button for 'Attending Provider' is displayed.
  • 'I' button: Selecting an Outside Provider as 'Attending Doc' for a Non-Capitation Claim is not allowed.
  • Remittance >> EOB/ERA screen:  The EOB/ERA for Capitation Type Claims displays the Capitation Insurance name in the 'Pri Ins' column.
  • Remittance >> EOB/ERA screen:  The EOB/ERA for such Capitation Type Claims displays the word 'CAPITATION' in bold and red font in the top-right corner of the middle frame.
  • Remittance >> EOB/ERA screen:  The 'Allowed Amount' against each charge code in 'Capitation' type claims included in the EOB/ERA is 'Auto Written Off' in red font.
  • Remittance >> EOB/ERA screen:  The Copay is automatically applied by the system if collected. But the charge row remains enabled as long as the EOB is not posted so that the 'Copay' can be edited if required or as asked by the Insurance in the EOB received.
  • Remittance >> EOB/ERA screen:  When the selected claim is of type Capitation, and it is Normal (Not Additional / Duplicate), then the amounts in the charge line remain enabled and the 'Copay' amount can be edited if required.
  • Settings >> Conf. >> Medics >> Ref Doctors: When the property 'billing.capitation.outsideproviders' is set to 'Y', an additional field with the Label as "% of Medicare" is displayed. This accepts a value from 0 to 200. The clinic pays the Outside Provider as per the negotiated % of the Medicare rate.
  • Patient Account Screen: The word 'Cap' in bold and red color is displayed before the Insurance name under the 'Claims' section in the 'Billed To' column to notify that the specific claim is a 'Capitation' type claim.
  • Reports >> Tabular:  The PrognoCIS TM system has an added capability which allows the generation of Tabular Reports to analyze the capitation amount received from various Insurance companies against the amount that would have been received from 'Medicare'. These kinds of reports provide visualization of the actual profit/loss incurred by the Provider when the 'Allocated' capitation amount is received, as against what they would have received as payment for claims from the Insurance companies.  There are three custom reports mentioned as follows:
    • Report 'CAP01': Capitation Amt distribution per Claim – computed
    • Report 'CAP02': Capitation Amt distribution per Attending Doc
    • Report 'CAP03': Capitation Visit payments to Outside Provider

Validations on Claim Screen:

• Secondary insurance is not allowed when the claim has Primary Insurance of the type 'Ins. Capitation'. The system validates this condition on the 'Save' action of the claim. An error message is displayed and the claim is not allowed to be saved until the Secondary Insurance is removed. The error message: 'Primary is Capitation. Cannot select Secondary Insurance'.

Process a Capitation claim:

Capitation claims are processed like a normal insurance claim.

• Enter details about procedures, ICD, and HCPCS/CPT.
• The fee is populated from the fee schedule associated with the Insurance on the Insurance Provider.
• Click the 'Save' button to retain the changes.
• Mark the 'Ready to Send' checkbox.
• Click the 'Save' button to change the claim status to 'Ready to Bill' from 'Ready to Send'.
• Use either of the two methods to post the claims:
  • The 'Send' button - It is enabled once the claim is marked as 'Ready to Send' after saving the claim.
  • Navigate to the 'Send Claims' screen to process the claim.
• The 'Void' button is enabled only after the claim status is 'Billed'.

Create Remittance for Capitation Type Claims:

Although 'IPA' type Insurance companies pay in a lump sum amount (monthly/quarterly) to clinics, these insurance companies still need claims and send the EOB/ERA against such claims. The Insurances typically send a Paper EOB.

• Create an EOB for the 'Payor' which has a 'capitated' type of Insurance Plan. Select a 'Payor' whose insurance type is of 'Ins. Capitation'.
• Enter the required details like 'Check No.', 'Check Date', and 'Check Amt'.
• In order to select claims in the EOB, click the claims search binocular icon. Select the claims in the EOB which might contain other claims as well which are not 'Capitation' claims.

Note: The 'Allowed' amount is pulled on the EOB/ERA from the 'Allowed' Fee Schedule defined for the Insurance of Capitation type.

Important aspects to be noticed in Middle Frame

• When a Capitation type claim comes into focus, please note the following on the EOB screen:
• The text 'CAPITATION' is displayed in red and bold font on the top-right corner of the middle frame.
• The 'Pri Ins' column displays the Primary Insurance name in black and bold font.

Important aspects to be noticed in Lower Frame

• When a Capitation type claim is selected on the EOB screen:
• The charge row line remains enabled unless the EOB is posted.
• Copay, if collected, is applied automatically.
• The user can modify 'Copay' if required or as instructed by the Insurance.
• The system smartly differentiates whether the EOB/ERA received is from the 'Normal insurance type' or the 'Capitation Insurance Type' whenever an EOB/ERA is created and, accordingly, the 'Allowed Amount' is Auto Written Off and is set to '$0'.
• Mark the 'Ready to Send' checkbox and click 'Save' to post the EOB.

Validations on EOB Screen

General validations are carried out on the EOB screen, which are listed below for reference:

• For Check No. - After the field 'Check Amt' is filled in, if the field 'Check No.' is blank and the EOB is saved, then an error message is displayed on saving the EOB. Msg - 'Check No. is mandatory'.
  
• PrognoCIS forcefully treats any Payor entered in the 'Payor' field on the EOB screen as a 'carrier'. As the 'Payor' is always treated as a 'carrier', it becomes important to ascertain the specific insurance. With the specific insurance ascertained, 'Remaining Amount' can be used under the 'Move To/ Used From' advance. If the insurance is not selected in the 'For Remittance' pop-up, an error message is displayed - 'Select Insurance From Remaining Amt Hyperlink'. This validation is carried out when the EOB is marked as 'Ready to Post' and saved.
  

Payment - Capitation Receipts

A 'Capitation Receipt' entry is created for the capitation amount received from the Insurance Company for various claims with the Insurance Type as 'Capitation' for a defined period according to the agreement/understanding between the Clinic and the Insurance Companies. PrognoCIS provides the capability to create a 'Capitation Receipt' using the menu option: Remittance >> Capitation Rcpt. 

To generate Capitation Receipts, click the 'Add New' button. By default, the 'Receipt Date' field is populated with today's date, although it can be less than today's date. When the 'Receipt Date' is greater than today's date, an error with the message 'Receipt Date greater than today's date' is displayed on save.

Enter the payor name in the 'Insurance' field, and here also, the insurance is treated as a 'carrier'. Enter the 'Received Amt' for the capitation claim and save the capitation receipt. Enter the comments in the 'Capitation Receipt Comments' field.

Validations on Capitation Receipt Screen

• When the 'Receipt Date' is greater than today's date, then an error with the message 'Receipt Date greater than today's date' is displayed on save.
• The entry about 'Rendering Provider', 'Location', 'Business Unit', and 'Attending Doc' should be completed, which is present on the 'Info' button. Whenever a single field is found to be 'blank' on the 'Info' button, the following alert message is displayed: 'Please select Rendering Provider, Location and Business Unit from Info button and click Ok'.
• When the 'Received Amount' is entered and the 'Pay Mode' is selected as 'Check', then the system applies a validation to check if 'Check Date' and 'Check No.' are present or not. If not, the alert message is displayed: 'Check No is Mandatory.'
  

Track and Analyze Capitation Amounts - Capitation Report

Reports in any system are used to analyze the factors which are taken into consideration while creating reports. The PrognoCIS TM system has an added capability which allows the generation of Tabular Reports to compare the capitation amount received from various Insurance companies against the X% of the amount that would have been received from Medicare. These kinds of reports provide visualization of the actual profit/loss incurred by the Provider by comparing the actual capitation amount received from the Insurance companies against the capitated plan and what they would have received as payment for such claims as the X% of the amount from Medicare. Medicare is considered a benchmark among Insurance companies. Providers compare the 'Allowed' amount received from Medicare and the calculated 'Allocated' amount as a percentage of the 'Allowed' amount from Medicare for capitation-type claims.

Prerequisite to generate Capitation Reports in PrognoCIS

• Availability of the 'Medicare Allowed Fee Schedule'.
• The 'Medicare Allowed Fee Schedule' must be assigned to the Insurance Company having the Insurance Type as 'Ins. Capitation'.

General Features of the Tabular Report:

• The 'Sort' feature enables the user to sort the columns in the report.
• The 'Save As' feature allows the generated reports to be saved in the system, which can be referred to later.
• Export the report in 'CSV' format on a local machine or network using the 'Export' feature.
• Print the generated report either as a hard or soft copy.

There are three well-organized reports based on three different criteria:

• Report 'CAP01': Capitation Amt distribution per Claim – computed
• Report 'CAP02': Capitation Amt distribution per Attending Doc
• Report 'CAP03': Capitation Visit payments to Outside Provider

1. CAP01: This report computes the payment for each charge code of a capitation claim based on the Medicare Allowed Amt and the monthly capitation receipt. The claims considered are for the date range selected and the Capitation Receipt entry considered is of the next month.
2. CAP02: This report computes the amount to be paid for each charge code of a capitation claim for an attending doctor based on the percentage of Medicare contracted with him. The attending doctor could be any internal doc or outside provider defined as a referring doctor and associated with the capitation claim.
3. CAP03: For capitation insurance patients, if a specific procedure is required which cannot be provided in the clinic, then it is the Clinic's responsibility to get it done from an Outside provider and pay the Outside Provider. The Outside Provider sends a CMS 1500 to the clinic, and the clinic pays the Outside Provider as per the negotiated % of the Medicare rate. The clinic further raises a claim and sends it to the Insurance. This report allows the user to get a list of all capitation visits done by outside providers and the amount to be paid to them based on the negotiated % of the Medicare rate. The report allows selecting a single outside provider or ALL outside providers associated as the attending doctor on capitation claims from the referring provider list.

Capitation Claims Entry on Patient Account Screen

The Patient Account Screen displays the Insurance Name prefixed with the word 'Cap' in bold and red color font under the 'Claims' section in the 'Billed To' column.