Pre-requisite

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

Creation of Capitation Claim:

Creation of Capitation claim from EMR side

An Capitation claim is created from EMR side only if

1. The patient has valid Primary Insurance having Insurance type as 'Ins. Capitation'.
2. Assign valid Primary Insurance having Insurance type as 'Ins. Capitation' from Patient Insurance Screen.

Default Info on Claims >> Edit screen

When a Capitaition Claim is created,

• Word 'CAPITATION' is displayed in red and bold font when claim is saved.
• Button ‘send’ disabled.
• Button ‘void’ disabled.

For creating a Employer claim from Claims>>New screen directly:

Create a claim where patient has valid primary insurance and it's 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 Capitation Claim

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

Process an Capitation claim:

Capitation claims are processed like a normal insurance claim.

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

Create Remittance for Capitation Type Claims:

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

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

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

Important aspects to be noticed in Middle Frame

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

Important aspects to be noticed in Lower Frame

• When Capitation type claim comes is selected on EOB screen
• Charge row line remains enabled unless EOB is posted.
• Copay if collected, applied automatically.
• User can modify 'Copay' if required or as instructed by Insurance.
• System smartly differentiates whether EOB/ERA received is either from the ‘Normal insurance type’ or ‘Capitation Insurance Type’ whenever EOB/ERA is created and accordingly, ‘Allowed Amount’ is Auto Written Off and is set to ‘$0’.
• Mark checkbox 'Ready to Send' and save to post the EOB.

Validations on EOB Screen

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

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

Payment - Capitation Receipts

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

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

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

Validations on Capitation Receipt Screen

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

Track and Analyse Capitation Amounts - Capitation Report

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

Prerequisite to generate Capitation Reports in PrognoCIS

• Availability of ‘Medicare Allowed Fee Schedule’.
• ‘Medicare Allowed Fee Schedule’ must be assigned to Insurance Company having Insurance Type as ‘Ins. Capitation’.

General Features of the Tabular Report:

• ‘Sort’ feature enables user to sort the columns in the report.
• ‘Save As’ feature allows the generated reports to be saved in the system which can be referred later.
• Export the report in ‘CSV’ format on local machine or network using ‘Export’ feature.
• Print the generated report either as 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 Medicare Allowed Amt and monthly capitation receipt. The claims considered are for the date range selected and the Capitation Receipt entry considered is of next month.
2. CAP02: This report computes the amount to be paid for each charge code of a capitation claim for a attending doctor based on the percentage of medicare contracted with him. The attending doctor could be any internal doc or outside provider defined as referring doctor and associated to capitation claim.
3. CAP03: For capitation insurance patients if a specific procedure is required which cannot be provided in the clinic, then it’s the Clinics 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 negotiated % of Medicare rate. The clinic further raises a claim and sends it to Insurance. This report allows user to get list of all capitation visits done by outside providers and amount to be paid to them based on negotiated % of Medicare rate. The report allows selecting single outside provider or ALL outside providers associated as attending doctor on capitation claims from referring provider list.

Capitation Claims Entry on Patient Account Screen

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