Managing Enrollment and Eligibility Lists for Accurate Monthly Payments in Healthcare

March 1, 2023

Managing Enrollment and Eligibility Lists for Accurate Monthly Payments in Healthcare

As you enter into more capitation contracts, manually keeping track of the constantly changing list of eligible beneficiaries can be a significant burden on your revenue cycle management (RCM) staff.

Underpayments and overpayments are two of the biggest issues for organizations that participate in capitation arrangements. Underpayments can lead to cash flow problems for your practice, while overpayments can result in the need to repay funds months or even years after they were initially received. With manually reviewing eligibility lists every month, the risk of errors increases, and staff burnout is a real concern.


A Better Way to Adjudicate

But it doesn’t have to be this way. By implementing software that automates eligibility verifications, you can simplify the process and ensure that your PMPM payments are accurate and up-to-date. Here are some of the key features to look for in such a solution:

  • Intuitive Mapping Utilities: Software that adjusts as you onboard new capitation contracts will save you time and eliminate the risk of human error.
  • Automated Assignments: Automated matching of members with primary care providers (PCPs) and alternative care providers during the enrollment process streamlines the process and ensures accuracy.
  • Clear Enrollment Dates: Having a clear understanding of the covered period for each member is crucial to managing capitation payments effectively.
  • Reassigning Members: The ability to reassign members to different PCPs throughout the duration of a capitation payment contract period, with automatic adjustments to each PCP’s payment, makes it easier to manage changes in eligible beneficiaries.
  • Accurate Tracking: Detailed tracking for each covered member, including the ability to document deviations and easily adjust accounts if there is a delay in eligibility information, will help you stay on top of changes and avoid overpayments.
  • Eligibility Tracking Tools: Software that provides tools for tracking both provisional and active beneficiaries prior to receiving capitation payments from payers, with a well-defined audit trail, will give you peace of mind and help you stay in compliance with regulations.
  • Payment Reconciliation: Actionable reports that surface errors by comparing actual payments with expected payments on a per member/month basis.


Reap the Rewards of Smarter Claims Processing

By implementing a flexible claims process solution, you can overcome the challenges of keeping your member enrollment and eligibility lists current and ensure that your PMPM payments are accurate. The result will be a smoother, more efficient RCM process and improved financial stability for your practice. Don’t let the challenges of capitation payments keep you from advancing in value-based care. Invest in a solution that will help you stay ahead of the game and stay focused on what really matters: providing quality care for your patients.

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