Setup: Capitation fees are entered as separate fee schedules attached to the individual insurance plan.
Daily Use: The Treatment Planner Fee column will list the co-payment for each procedure, which is also the amount posted to the account when the procedure is set complete. The patient portion is the same as the fee column, and the insurance column will display zeros, showing no portion is covered by insurance.
When the procedures are set complete, the day's charges displayed in Ledger will automatically list the correct amount to collect from the patient. No adjustments are necessary.
Management: The Utilization Report can be sent monthly to the carrier as required and/or used for utilization management within the practice. For management purposes, the report lists the practice or provider's normal fee for each procedure completed and the co-pay charged, and totals these items for each individual plan.
If your practice supports fewer than six capitation plans, create a new billing type for each individual plan. If your practice supports more than five plans within a given company, you can choose a grouping of several plans and add a billing type for each grouping. Or, if your practice services several different capitation carriers, you can add a billing type for each company name. Your end goal is to use no more than five billing types for capitation purposes.
For each plan, create a fee schedule with the correct fees.
Add the capitation plans as individual insurance plans in the database:
From Family File, select a plan subscriber. If the insurance plan already exists in the database, you can edit it, according to the specifications explained here. If it does not already exist, create a new insurance plan, entering in the carrier name, address, etc.
In the Insurance Plan Information dialog box, attach a fee schedule that corresponds to the plan being entered.
Edit the coverage table information. Any coverage table can be selected, but the default or another general table is recommended. Change all percentages for each procedure category to 0%. Ensure that the Co-payment Calculation for Ins Portion checkbox is not selected before clicking OK.
Capitation Patients Per Visit: On all visits, you can treatment plan and post procedures normally. After posting the day's procedures for the given patient, the Today's Charges and Est. Patient Portion amounts in the Ledger will reflect the total co-payments for the current day. The Est. Dental Ins. Portion will always be zero.
Claims: Create a claim for the procedures and enter a zero payment on the claim. The claim will not require printing. The insurance payment will appear on the day sheet.
Monthly Operations/Management Analysis: If a Utilization Report is required for submission to the insurance carrier, this list can be printed at any time for a given date range.
Optional: A capitation plan "family" can be entered to record monthly payments from each plan to show on the receipts reports. You can add a new payment type to Practice Definitions. The amounts can be written off so that the balances of the capitation families are always zero. You will need to add a new adjustment type for this task. You can also assign these families a special billing type.