Medisoft Advanced DOS: Approach for
Managed CareNOTE: Medisoft Advanced for Windows is Case
based with Managed Care features built in.
DOS based Medisoft Advanced for Managed Care has two unique requirements for proper entry
of charges and reporting:
To take care of this growing segment of the health care market, MediSoft is developing the Managed Care module the Windows Advanced product which will automate these required operations. Until the fully automated version is released, you can perform these functions within MediSoft as shown hereinafter.
Managed Care is the growth area of health care. SafeMed Systems is committed to making patient accounting under MediSoft for Managed Care as simple and automated as the fee-for-service billing in MediSoft.
Capitation is a common payment mechanism of HMOs. The first principle you must learn about capitation is there is no relationship between (a) the capitation payment received by the practice and (b) the account of any patient covered by that payment. A capitation payment is a prepayment to a doctor's practice for all covered services needed by the patient. (Some plans limit major services, i.e., organ transplants, etc.)
The requirement for capitation in MediSoft is to zero out the patient's account balance each month. Because some capitated plans need a report of services rendered under their plan, and your Medisoft system has the data required for comparative analysis, you therefore must enter the charge for services in the patient's account. For Managed Care this is done be creating a transaction entry like you would do for regular fee-for-service account. Additionally, the entry must be matched by a credit adjustment procedure code (B-type insurance adjustment in MediSoft 2-5) in the same amount as the charge (or first entry) transaction. The patient's account now contains the charge transaction(s)--both charge and adjustment--and has a zero balance.
This will allow you to print reports and claim forms as usual. Remember, charges print on forms, adjustments do not.
Important.- The "B"-type procedure code adjustment should be unique to the capitated carrier. For example if the carrier is Aetna, you could use "ACWO" for the Aetna Capitation Write-Off procedure code (something easily remembered). Use this code only for Aetna capitated patients under that plan. Make a different code for each capitated plan.
Capitation is controlled in MediSoft in the Patient Information screens (2-1). To make it function properly, you must be sure to answer "Yes" to the Capitation question in 2-1 on the Policy #l screen of each patient involved. This prevents the generation of insurance claims. If a Managed Care Plan (insurance carrier) wants claim forms to be submitted, answer "No" to the Capitation question.
Measuring Performance
At the end of any month, you should compare the write-offs for a particular carrier (See amount of "ACWO" code in Practice Analysis specific reporting for the month) with the amount of the capitation check you received for that month. This will tell if you made any money on this block of business. Suggestion: compare a six to eight month period and average the months for a more accurate indication.
You could also put the two entry codes (charge and write-off) in a MultiLink procedure code for faster data entry in 3-1. Note: Medisoft menu (2-6) Multi-Link Information where you can automatically link up to eight procedure codes by entry of one. It is possible to chain MultiLink Procedure codes, IE., "a" chains to "b" and "b" to "c" to "d", etc. without limits. In this case "a" would create 32 unique transactions (actually 8 unique procedures for each multilink).
This is a method of paying health care providers for individual medical services rendered, as opposed to paying them salaries or capitated payments. This payment mechanism is more common among PPOs in managed care.
Typically an employer or Carrier will contract with the doctor to provide services to their policy holders for a scheduled rate. The amounts or percentages are spelled out in the policy benefits, and that is the maximum amount the provider is allowed to charge. There may or may not be a copayment involved.
Within MediSoft, this arrangement can be handled in two ways.
1. Set up your multiple fee schedule (MediSoft Advanced feature) with the scheduled amount for each service offered. The entries reflect the correct billing amount and you can bill the carrier and/or patient according to the policy benefits.
2. (Above) Enter the full amount (Standard Charge) of your fee for each service; followed by an adjusting entry to reduce the charge to the scheduled amount. From a practice management approach, the second method is superior as it shows you how much you have written off for this block of business. It facilitates decision making at renewal time for the group.
General Definition of Managed Care--Glossary
Any system of health service payment or delivery arrangements where the health plan attempts to control or coordinate use of health services by its enrolled members in order to contain health care expenditures, improve quality, or both. Transactions often involve a defined delivery system of providers with some form of contractual agreement with the plan.
A health insurance payment mechanism in which a fixed amount per person per month is paid to a provider for covered services whether the patient is seen or not.
A health insurance policy provision that requires the insured party to pay a portion of the costs of covered services. Deductibles, coinsurance, copayments, and balance bills are types of cost sharing.
A type of cost sharing where the insured party is responsible for paying a fixed dollar amount per service. It is used more generally as a synonym for cost sharing.
Deductible
A type of cost sharing where the insured party pays a
specified amount of approved charges for covered medical services before the insurer will
assume liability for all or part of the remaining covered service fees.
MediSoft MediSoft is a patient accounting and electronic billing system designed to track and manage patient encounters within a doctor's practice and prepare billing documents and/or medical claims for submission for third party reimbursement. It is the accounts receivable module of the practice management accounting system. Back to SafeMed HomePage