Fee Schedules in Capitation Provider Contracts
The WSMA believes health plans should include an attachment in
capitation-based physician or non-physician provider contracts entitled,
“Compensation Schedule for Capitation Contracts” that includes the
following: A) the amount to be paid per enrollee, per month; B) the manner
in which the insurer will determine who is an enrollee at the beginning of
any particular month; C) the precise terms of the stop loss arrangement;
D) the boundaries of the service area; E) the fee-for-service schedule to
which this compensation arrangement will revert in the event the number of
enrollees assigned to physicians or non-physician providers falls below a
designated actuarial minimum and what that minimum is; F) the number of
covered lives and the fee-for-service schedule upon which physicians or
non-physician providers will be paid for those covered services provided
to enrollees not specifically made a part of the capitation arrangement.
Physicians shall have the right to audit the books and records of the
company or a payer solely for purposes of determining the accuracy of any
capitation payment; and, G) the complete list of services expected in
return for compensation. (Res C-8, A-99) (Reaffirmed A-23)
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Abbreviations for House of Delegates report origination:
EC – Executive Committee; BT – Board of Trustees; CPA – Council on
Professional Affairs; JC – Judicial Council; CHS – Community and Health
Services