Configure Capitation and Capitated Plans

When your practice has a contract with a “capitated” insurance plan, you will automatically write off the cost of many procedures right when a patient is seen. You will post a monthly capitation check from the payer.

Read the steps below to learn how to create appropriate insurance groups, plans, a fee procedure to offset the monthly payment, a payment type, and a holding account to record and track capitation payments on your system.

PCC Support Completes This Setup: PCC Support will complete the steps in this article for you, or we can walk you through the process. The instructions below are published for users who administer their practice’s tables and wish to make updates or review their configuration.

The example below is for a capitated insurance company called “INSCO INSURANCE”.

Contents

1 Create the Table Entries for Tracking Capitation
2 Add a New Patient and Account For Tracking Payments
3 Post Capitation Payments

Create the Table Entries for Tracking Capitation

Use the Tables tool to create insurance groups, plans, fees, and payment types.

Create Two New Insurance Groups
For reporting purposes, create two new insurance groups.
1. Open the Tables tool from the Configuration menu.
2. Open the “Insurance Groups” table.
3. Add Two New Insurance Groups:
  - INSCO INSURANCE
  - INSCO INSURANCE Cap Clearing
  As you create the new groups, use sequential numbers in the “Reporting Position” field. This will help the two groups appear together on various reports.
Create New Insurance Plans
1. Open the “Insurance Plans” table in the Tables tool.
2. Add a new insurance: “INSCO INSURANCE Cap Clearing”. Make sure it uses the INSCO INSURANCE Cap Clearing group. This plan will be used to track capitation payments.
3. Next, add new insurance plans to the table that will appear as policies on patient accounts.
4. PCC Support’s billing specialists will configure these plans to automatically adjust off procedures in accordance with your contract with the payor.
As you encounter patients with the plan add it to their records as you would any other insurance plan.
Create the Capitation Fee Procedure and Payment Type
1. Open the “Procedures” table in the Tables tool.
2. Add a new procedure called “Capitated Fee”. This will be the procedure which offsets the incoming capitation payment from the payor.
  - Give the procedure an accounting type of Revenue – Non-service
  - Add an appropriate procedure group for reporting purposes. You might decided to create a new procedure group to track capitation income.
3. Open the “Payment Types” table
4. Add a new payment type called “Capitation Check Payment”
  - Give the new payment type a payment class of “Check”
  - Make it available for personal, insurance, and charge posting payment posting.

Add a New Patient and Account For Tracking Payments

You will use holding accounts to enter capitation payments.

Create a new patient record. First name: INSCO INSURANCE, Last name: Cap Clearing.
As you create the patient, add a new parent billing account. First name: INSCO INSURANCE, Last name: Cap Clearing.
In the patient’s record, add the insurance “INSCO INSURANCE Cap Clearing” to the patient’s policies. Provide a start date that precedes any capitation plan activity you need to record.

Post Capitation Payments

In order to not deflate your A/R with a credit, you will post the Capitated Fee procedure as an offset and then post the Capitation Check payment. The incoming check will pay off the procedure, creating no change in your A/R.

To learn how, read Post Capitation Checks, Incentive Payments, Interest Payments, Overpayments, and Withhold Payments, or watch the tutorial video.

Here are some related articles in Billing and Practice Management > Bill Insurance:

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Create the Table Entries for Tracking Capitation

Add a New Patient and Account For Tracking Payments

Post Capitation Payments

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