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Payment Reconciliation and Audit Tools: The Key to Navigating the World of Capitation Contracts with Confidence

BLOG | March 28, 2023

CGT_CAPAs healthcare delivery organizations shift towards capitation payment arrangements, there are increasing challenges to maintaining revenue cycle management (RCM) accuracy. It’s essential to have integrated reporting tools to monitor claims’ progress through the adjudication process. This includes payment reconciliation capabilities, which give administrators the ability to ensure payment accuracy and pinpoint instances of overpayment or underpayment.

Stop-loss insurance is common in alternative payment models that place financial risk on the provider.  It protects against unforeseen costs that can result from catastrophic medical incidents that an attributed member might experience. However, many providers don’t have integrated capabilities to audit and report on stop-loss amounts paid by members.

Here are some tips for healthcare delivery organizations to navigate capitation contracts confidently and efficiently:

  • Leverage Payment Technology Solutions: The key to making sure that capitation payment accuracy is maintained is to use payment technology solutions that have integrated checks and balances that are specific to capitation. These solutions should be able to calculate the correct monthly payment amounts and pay them out to the appropriate entities within a capitation agreement. Finding a tool that can automate these capabilities eliminates the need for manual work by revenue cycle and finance teams, saving time and money.
  • Simplified Reporting Tools: Healthcare organizations should use simplified reporting tools that seamlessly connect to payment technology software to review and audit claims payments after they are made. This reporting software should provide information on stop-loss payments based on a number of customizable criteria, making it easier for organizations to identify gaps in their financial protection.
  • Easily Sort Data: The best technology software will allow you to easily sort data by specific parameters, such as member, practitioner, contract, and more. These features provide real-time insights into payments and highlight potential areas where corrective actions may be needed.
  • Customizable Reports: Customizable reports should be able to be shared system-wide for any user. This approach ensures that all departments, including revenue cycle management, finance, and medical management, can access data on-demand and have access to the information they need to be successful.

The benefits of these tips are significant. They include:

  • Increased accuracy in capitation payments and stop-loss reporting, reducing financial risk for providers and payers
  • Simplified and automated processes that save time and money
  • Customizable reporting tools that provide real-time insights and enable easy monitoring of performance metrics

Healthcare providers and payers should take full advantage of the technology tools available to them to ensure accurate and efficient management of capitation payments. Using these tools enables organizations to streamline processes and mitigate financial risk, ensuring a bright future for healthcare delivery in a capitation-based world.

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