Overview

History of Capitation: Highlights important events and dates leading to today's managed care delivery systems.

Patient Care: Explains referrals and pre-authorizations, the gatekeepers role, emergency room rules, out of area rules, limits placed on patient visits and the rational for using patient copayments. Your patient care knowledge is tested with a true false exercise.

Capping the Physician: Describes fee-for-service reimbursement, hourly reimbursement, procedural reimbursement and the RVS and RBRVS payment systems. Billing and subscriber eligibility are presented. The origins and influence of the Independent Practice Association are discussed.

The Marketplace: Reviews market competition before and after managed care, as well as examining the numerous organizations involved. Funding sources are discussed, including Federal and State governments, the stock market, private funding and employer employee funding. Taxation issues for non-profit and for-profit payers are considered.

Doing the Math: The HMO, hospital, ancillary provider, physician, employer and employee represent the participants in managed care. Each is measured by financial standards and tools. Tools include calculating capitation rates for a prepaid physician group, calculating premium rates using community rating by class or group specific rating, per 1000 cost calculations and others. A sample cost model is provided, as well as spreadsheets explaining how IBNR is predicted and how costs are applied to the procedures performed by private practice physicians.

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