Participation in capitated reimbursement contracts (financial arrangements where physicians are paid a fixed amount for each patient assigned to them) can offer physicians a routine and sustained source of monthly income for their practice. Capitation, however, can be a complicated process. It is essential that physicians monitor their monthly capitation reports to ensure they are being paid per the terms of their agreements.

Under many capitation arrangements, physicians are typically paid a fixed amount per member/per month for each patient assigned to them, regardless of whether the patient receives care during the month. Ensuring that patients are properly assigned to the physician is essential for the management of any capitation relationship. Some payors make no effort to proactively ensure that enrollees pick a primary care physician (PCP) upon enrollment, resulting in the delayed payment of capitation until a PCP selection is made.

For more information on capitation arrangements, see CMA health law library document #7100, “Capitation, Including Risk Adjustment.”

Contact: CMA’s reimbursement helpline (888) 401-5911 or economicservices@cmadocs.org.