Optimizing capitation billing

The health and business case for capitation is well established among physicians and patients, notwithstanding the various flaws in execution that many Canadian doctors have pointed out. In theory, at least, the pay-per-patient concept is viewed widely as an effective way to stabilize healthcare funding and physician compensation while improving patient access to team-based care and easing doctors’ workloads. “But from a billing perspective, capitation is so much more complex,” said Paulo Gomes, managing director at DoctorCare, a Toronto-based national provider of billing technology solutions for physicians. “There are a lot of extra incentives involved, and a lot of checks and balances in place.” This makes it easier for doctors—or their administrative staff—to overlook billing opportunities that, when all added up, can translate into significant losses in practice revenue/ Gomes offers some suggestions for optimizing billing within a capitation payment mode. Bill for everything you can This may sound like obvious, commonsense advice, said Gomes, “but we know from working with physicians on capitation that many have missed out on as much as $30,000 in billing opportunities per year. That’s why it’s important to take the time each month to analyze your billing to ensure you’re not failing to bill for items such as extra incentives, he added. It’s also a good idea to double check that billable tasks, such as patient rostering, are getting invoiced as they’re done. If your billing program has an analytics function, use it to comb through your invoices to identify codes and special premiums that you should’ve invoiced for but didn’t. Do this regularly, ideally at intervals that ensure you won’t go over claim eligibility periods. Stay on top of incentive codes Most incentives, such as preventive care bonuses, are designed to promote better care while providing extra compensation for physicians. Make sure you’re aware of all the incentives associated with the services you provide, advised Gomes. “This could be like codes for preventive care bonuses based on meeting certain thresholds for cancer screening, or immunizations for children and seniors, or premium codes for taking on complex patients,” he said. “If you haven’t done it yet, build shortcuts for these codes in your EMR, as well as reminders and alerts so you’re not missing anything." Boost your patient outreach Encourage your patients to come in for services, such as immunizations or preventive screening, that are tied to incentive-based payments. This could mean getting your front-office staff to call patients for appointments, or sending out reminder emails from your secured communication platform. Get a handle on your patients’ outside use Review your billing reports to identify which of your rostered patients occasionally—or, in certain cases, perhaps frequently—see practitioners outside your clinic. Regardless of how often or how many of your patients seek care outside your clinic, it’s good practice to educate your patients about their options for after-hours care within your practice, and to provide them a list of health-ministry designated urgent-care sites they can visit without triggering an outside-use deduction. “A lot of patients assume that their family doctor’s clinic is only open during certain hours during the week and they don’t realize that their family doctor has colleagues who are on call on evenings and weekends,” said Gomes. “Make your patients aware of these things and remind them throughout the year.” Deroster where it makes sense Do you have patients who, despite your best efforts, continue to make frequent visits to walk-in clinics or are starting to transition to another family doctor with a particular focus, such as mental health or chronic pain? What about the ones who have moved out of town but still come in to see you every once in a while? Removing these patients from your clinic’s roster may make sense, said Gomes. “If they do want to continue seeing you, you can still have them come in as non-enrolled patients on a fee-forservice basis,” he said. “This way you’re not getting penalized every time they see someone outside your practice.” Get a second—or third—opinion When in doubt, an expert opinion always helps. Even if you think you have a good grasp of capitation billing practices, it’s not a bad idea to talk to your invoicing system or services provider about what else you can do to optimize your billing.

Optimizing capitation billing

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