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Tracking Risk and Quality Scores at the Member Level: The Key to Maximizing Reimbursement in a Capitated Payment Model

BLOG | March 8, 2023


The healthcare industry is moving towards value-based payment models, and capitation is one of the most popular. It provides a predictable revenue stream for providers and aligns incentives to deliver high-quality care at a lower cost. However, maximizing revenue in a capitated payment model depends on accurate risk and quality scores for each member. Without this, providers could be leaving money on the table.


Key Elements to Achieving Accurate Risk and Quality Scores for Condition-Specific Capitation Program Contracts:

  • Payment technology software specifically designed for capitation payments – Using software that is specifically designed for capitation payments enables providers and payers to track individual member attributes, including individual risk scores. This helps ensure that per-member per-month (PMPM) payments can be projected based on the contract parameters and risk profile of each member.
  • Customizable member fields – Customizable member fields provide flexibility to track information that is pertinent to the contract. This feature allows for defining the specific data to capture and report on throughout the duration of a contract period. This ensures that the correct data is tracked for each member, and the reports generated provide valuable insights for decision-making.
  • Near-real-time tracking of member risk and participation – Tracking member risk and contract attribution in near-real-time is critical to ensure the most up-to-date information is used to calculate monthly payments. This feature helps payers and providers avoid outdated member lists and inaccurate payments that must be reconciled and adjusted later. It enables quick decision-making and course correction while eliminating under- or overpayments.

By incorporating these key elements, providers and payers can achieve accurate risk and quality scores for condition-specific capitation program contracts. This helps ensure that payment technology software can identify and track the specific information for each individual member and the providers they are aligned with, provide accurate revenue projections, and reconcile PMPM payments each month.


Benefits of Accurate Risk and Quality Scores:

  • Reduced errors and rework – Accurate risk and quality scores lead to reduced errors and rework, minimizing under- or overpayments, and preventing delays in processing claims. This can help reduce the workload for revenue cycle staff members, who are often working under tight deadlines.
  • Improved financial projections – Accurate risk and quality scores help improve financial projections by ensuring that revenue projections are based on the specific information for each member. This enables better financial decision-making and planning for future capitation contracts with greater confidence.
  • Enhanced patient care – In addition to accurate payment, risk and quality scores enable providers to identify and target care management initiatives for high-risk patients, improving patient care and health outcomes. This collaborative effort can help reduce the total cost of care for the patient population.

Accurate risk and quality scores are vital to capitation programs, and one of the best solutions to achieve this is through payment technology software built from the ground up for capitation payments. Ready to learn more? Contact us today with your questions.

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