Managing Multiple Provider Contracts and Complex Capitation Models

February 17, 2023

Capitation-Adjudication-Blog-Post1As value-based care models become more prevalent in the healthcare sector, the complexities of capitation models are increasing. Current fee-for-service payment adjudication software is not equipped to handle the intricacies of partial or full capitation contracts and arrangements, leading to manual processes that allows errors and mistakes to slip in, negatively impacting financial performance on all levels.


The Solution for Capitation Adjudication

To deal with these new demands, healthcare payers and providers need capitation adjudication software uniquely built for value-based care alternative payment models (APMs), including full and partial capitation. The right capitation adjudication solution should:

  • Handle multiple capitation contracts and fee schedules
  • Manage the nuances of attribution and payment reconciliation
  • Enable providers and payers to meet and exceed performance thresholds of VBC initiatives

Beyond this, the software should also offer standard resource-based relatively value scale (RBRVS) Medicare fee schedules, as well as self-insured and commercial fee schedules, and an external pricing engine for fee schedules such as inpatient or outpatient prospective payment systems (IPPS or OPPS) and long-term care hospitals.

This requires a solution platform that’s easily adaptable and customizable for various payers, including CMS’ ACO REACH for partial-care capitation (PCC) and total care capitation (TCC) contracts, commercial payers, Medicare Advantage partial and global risk contracts, Medicaid or Medi-Cal, and self-funded employers.


Product-Screenshots-CAPThe Results of Capitation Adjudication Automation

Implementing capitation adjudication software can bring numerous benefits, including improved financial performance, increased operational efficiency, and enhanced patient outcomes. The software streamlines the claims adjudication process, cutting down on those critical errors and mistakes, and ensuring that all parties involved receive accurate and timely payments.

As technology can be both empowering and hindering for all parties involved, it’s essential for healthcare payers and providers to adopt capitation adjudication software that’s been designed specifically for value-based care alternative payment models.

Want to learn more about what that looks like in your organization? Let’s talk.

Your browser is out-of-date!

Update your browser to view this website correctly. Outdated Browser