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Compliance Risks and Overlapping Payments in Value-Based Capitation Models

Compliance Risks And Overlapping Payments In Value Based Capitation Models Web

Medical groups take on greater financial risk when they 实施基于价值的护理计划. 但合规风险也是存在的 this blog post expands on a common pitfall that healthcare organizations must avoid when implementing capitation models to pay PCPs for value-based patients-overlapping支付.

重叠的薪酬结构

PCPs who manage capitated patient panels are commonly paid through a base per member per month (PMPM) capitation rate plus a risk bonus. 然而, when physicians in the same group are paid according to different compensation formulas, 可能会产生意想不到的后果.

For example, imagine there are two physicians in a clinic, Dr. 史密斯博士. 琼斯. Dr. Smith is paid on a $/PMPM basis for a value-based population, and Dr. 琼斯 is paid on a productivity basis for an FFS population. 如果博士. 琼斯为一位云顶集团rt电子游戏提供护理. Smith’s patients, then overlapping compensation may occur, representing dual risk. 这是因为Dr。. Smith is paid on a $/PMPM basis for the patient and Dr. 琼斯获得了基于生产力的报酬.

In general, physicians in a group practice often routinely cover patients for other physicians. 如果博士. 史密斯博士. 琼斯 cross-cover patients evenly, then there is less financial and regulatory concern. 但如果博士. 琼斯云顶集团rt电子游戏通常为分配给他的病人云顶集团. Smith, unintentional overlapping compensation may occur (illustrated in figure 1 below).

Potential solutions to the challenge presented by overlapping service and duplicate compensation might include:

  • Pool value-based compensation across a pod or clinic location to blend the activity of the physicians.
  • Adjust $/PMPM payments to reflect the assessed amount of service overlap.

减轻你的接触

Ensuring there is no overlapping compensation or improper capitation payments is one of several challenges that medical groups must manage when transitioning to a value-based model. 然而, there are mechanisms and processes that organizations can put in place to mitigate compliance risk and ensure proper compensation for services under a value-based model. Aligning provider compensation with your organizational strategy of becoming a value-based entity is critical to financial success.

ECG is your expert partner for developing and managing your value-based strategy. Learn more about our work with value-based organizations.

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