Managed Care Contract Negotiations
Dec 19

Track codes under capitation

If you work under capitated contracts, file and track plan patients’ CPT codes, even though you get paid on a per-member per-month basis instead of an FFS basis.

Some capitated plans still require that claims indicate the services performed. This creates double work for your accounting department, because you must post the charges and then adjust to a zero balance. But this extra accounting can pay off for three reasons:

    1. You get paid for "bill-aboves" and "carve-outs."

    2. It helps you negotiate for higher premiums later.

    3. You can track provider productivity.

If your practice includes only some capitation, keep these three simple tips in mind:

  • Make sure you write off to "capitation" all charges covered by the capitated (per member per month) fees.
  • Track your capitation fee as well as services rendered. Use it as a payment for that patient that month. Then, offset the balance to end with a 0 line-item, using a "fake" CPT code like "CAP."
  • Have two fee schedules: one with all codes and charges, the other with all codes and zero charges (capitation).
About Reed Tinsley, CPA

As a top advisor to physicians, I help increase practice profits by delivering hands-on, expert medical accounting/tax support, practice counsel, and revenue-building strategies. Read more →