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A capitated plan is one where the patient is assigned to a doctor upon enrollment in the insurance plan and from that point on the doctor is paid a fee to be that person's doctor whether the patient is seen or not. Insurance companies like it because it makes their expenses more predictable and controllable and doctors often like it because it guarantees a steady income stream.
The hope is that doctors will find ways to keep the patient healthy and manage then efficiently, often using nurses and other providers. The down side is that it provides an incentive for the doctor to not want to see the patient or to at least minimize the time spent with them. The doctor does well if he can gain a large panel of healthy patients he rarely sees and does poorly with a panel of sick patients that are seen often.
The other type of plan is fee for service where the doctor submits a bill and gets paid only when he sees the patient.
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Why do charges need to be adjusted for patients who are covered under a capitated insurance plan?
Because they are not being charged on specific procedures. Under a capitated plan a flat fee is paid to the physician no matter how many times a patient receives treatment.
What is non capitated health insurance?
A managed care plan is non-capitated when there is no dollar amount set to cover the cost of health care services delivered for a member during a specified length of time.
Is a capitated payment prepaid to a provider to cover a plan members health services for a specified period?
yes
Can a PPO dentist be used in an HMO plan?
No. For one, in an HMO the providers are "capitated" paid part of the premium EVERY month, whether you use their services or not.
What are the critical differences in profit analysis when conducted in a capitated environment versus a fee-for-service environment?
Explain the critical differences in profit analysis when conducted under a capitated environment versus a fee-for service environment.
What would happen if a capitated patient account was not adjusted to a zero balance?
the patient would have to pay
What is capitated health insurance?
capitated health insurance is when a physician gets paid a specified dollar amount, for a given time period, to take care of the medical needs of a specified group of people. Often used in Health Maintenance Organization (HMO) Insurance Plans.
What is another name for a policyholder?
Insurance companies often refer to policy holders as "heads" (especially in capitated systems) or "lives".
Capitation payments are most characterstic of?
Capitation is the term used to describe the method of payment to health care providers under a managed care plan. It often is used with specific reference to heal maintenance organizations, and refers to the amount of money per month that the provider gets per enrollee. In return for the capitated payment, the provider is generally responsible for furnishing all care called for by the plan. One of the goals is to work efficiently in the provision of care and to keep the member well.
What is capitated pricing?
Capitated pricing is a model established that allows healthcare providers to purchase medical products and devices from a variety of OEMs at set levels based on the level of the product. For example there may be 3 levels: Standard, High, and Premium. Each OEM will establish their products that fall into each of these categories by a certain set of characteristics that make these products "equal" from a clinical effectiveness point of view. Then the healthcare provider will pay each OEM the same amount for any product in each level. For example: $3500 for all Standards, $5000 fro all High, and $7500 for all Premiums. The capitated pricing model also allows for OEMs to produce a special or "niche" product that does not fall into these categories if they can prove the clinical reasoning.
When a capitated patient's services go over a certain amount and the physician can begin asking the patient to pay fee for service this arrangement is provided in what section of the managed care cont?
it known as Stop loss limit
Name five payments types under managed care contracts?
The five payment types under managed care contracts are: 1. Discounted Fee-For-Service 2. Per Diem 3. Per Case 4. Percentage of premiums 5. Capitated arrangements
