Working with Capitation Plans

When working with a capitation insurance plan, the WinOMS software automatically keeps track of production performed on the plan, enabling you to analyze its profitability. You can also attach a fee schedule to a capitation plan, enabling you to charge for procedures not covered by the plan.

To indicate that a plan is a capitation plan, select a plan type of Capitation in the Plan Data Entry window.

Typically, the amount displayed on the Charge window is 0, even if a standard fee exists for the procedure. If an amount is entered, the patient is billed the amount, and the charge is not considered capitated. It is assumed that the procedure is not covered, and it is not included in the Capitation report.

Since many capitation plans do not cover certain procedures, you can attach a fee schedule to the plan and enter fees for those procedures not covered. In this situation, the fee is automatically posted during charge entry. Similar to manually entering a fee, the patient is billed the fee, and the charge is not considered capitated.

For a capitation plan with a limited number of covered procedures, create a fee schedule by copying your standard fee schedule and removing the fees for the covered procedures.

As long as a fee is attached to the procedure, it is considered not covered by the plan and is billed to the patient.