Capitation and Capitated Plans in the PCC Billing System

Capitation payments are not like other income. How should you configure the PCC billing system so you can enter and track capitation payments over time?

Read the steps below to learn how to create appropriate insurance groups, plans, and income accounts to record and track capitation.

For this example, we will create a new capitated insurance company, “PCC Insurance” and configure it so we can post capitated payments to it.

Create the Insurance Groups, Plans, Fees, Payment Types, and Accounts to Record and Track Payments

In order to track payments, we will first create a number of items in PCC’s underlying tables. PCC Support will complete these steps for you, but you may find the instructions helpful if you are a Practice Management administrator and make updates to your PCC tables.

1. Create Two New Insurance Groups
   1. Open the Table Editor (ted) in Practice Management
   2. Open table #17, “Insurance Groups”
   3. Add Two New Insurance Groups:
      • PCC Insurance
      • PCC Insurance Cap Clearing
   4. Edit “Order” field with sequential order numbers. This will help the two groups appear together on various practice management reports.
2. Create New Insurance Plans
   1. Open table #3, “Insurance Plans”
   2. Add a new insurance: “PCC Insurance Cap Clearing”. Make sure it uses the PCC Insurance Cap Clearing group. This plan will be used to track payments.
   3. Add each new capitated plan with assistance from PCC Support’s billing specialists. These plans will appear as policies on patient accounts.
3. Create Capitation Fee and Payment
   1. Open table #6, “Procedures”
   2. Add a new procedure called “Capitated Fee”.
      • Give it an accounting type of Revenue – Non-service
      • Add it to the appropriate group for reporting purposes. You might consider creating a new procedure group to track capitation income.
   3. Open table #11, “Payment Types”
   4. Add a new payment type called “Capitation Check Payment”
      • Give it a type of Check
      • Allow it to be posted through Payment Posting (pam).
4. Add a New Account and Patient For Tracking Payments
   1. Create a new patient record. First name: PCC Insurance, Last name: Cap Clearing.
   2. Add the insurance “PCC Insurance Cap Clearing” to the patient’s policies.
   3. Create a new account record. First name: PCC Insurance, Last name: Cap Clearing.
   4. Link the new patient to the new account.

Post Capitation Payments

In order to not deflate your A/R with a credit, you will first post the Capitation Check Fee, and then post the Capitation Check Payment, so they create no change in your A/R.

1. Post the Capitation Check Fee
   1. Open Post Regular Payments (pam).
   2. Press F3 to open the Refund (refund) program
   3. Change the date to the date you deposited the check in your account.
   4. Select “Capitation Fee” as the adjustment type.
   5. Type in the amount
   6. Select a provider
   7. Press F1 to save
   8. Press F12 to exit Refund.
2. Post the Payment
   1. Change the date to be the date you deposited the check.
   2. Enter “Capitation Check Payment” as the payment type.
   3. Type in the amount, check number, and select a provider.
   4. Link the Payment to the Capitation Check Fee
      1. Press F4 to link the payment
      2. Select the number to the left of Capitation Fee and press enter
      3. Hit F1 to save your changes
      4. Hit F12 twice to exit the program

The account you added should always have a $0 balance. If it does not, you missed one of the steps above.