Insurances pay the providers in two ways, capitation and Fee-for-Service (FFS) arrangement. Each method has its own advantages and disadvantages. Before we dive into their pros and cons, let’s dive into their definitions and understand them:

“Capitation is a payment arrangement for health care service providers such as physicians or nurse practitioners. It pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.”

On the other hand, FFS or Pay-for-Performance is a payment method where services are unbundled and paid separately. In healthcare, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care.

So in simple words, in capitation, you, as a practice, provider or nurse practitioner receive a lump sum on periodic basis and in FFS, you receive individually for each service or treatment performed on a patient as per his/her insurance plan.

Now here is a key point, each time you enroll with an insurance or HMO (Health Maintenance Organization), you can sign up either with capitation or FFS. The question is which payment arrangement best suits you.

Here are the five factors that you need to consider before making the choice:

Number of Patients you treat per day

First of all, as a practice, you should have some idea about the number of patients you treat in a day. There is no definition or standard count on “more” or “less” but if you remain busy all day and there is no or very small duration of break in a day then you are probably a practice which treats more patients or if count of patient is low, you still use many procedures on one patient which might be keeping you busy with one patient. For example 2 or 3 heart surgeries would be too much work for a heart surgeon in one day. Now, if you remain busy then based on above analysis, FFS is the best choice. If you remain less busy then Capitation is better.

Budgeting & Costing

Capitation is an arrangement which is predictable. You know how much and how many capitation checks you receive in a month or during a predetermined time period. FFS is all dependent upon the number of patients or number of procedures that you do on one patient. If patients are less and you opt into FFS then obviously your collections will be less.

New Vs. Old Practice

If you are a new practice and the community beneficiary or potential beneficiaries are known to you or you, for the time being, cannot predict their count then capitation is better option. Because as mentioned above, capitation is a fixed payment arrangement and hence you can accordingly plan and manage your expenses and income. Patients are usually less attracted towards a new practice than an established and experienced practice so you can make more for less treatments or patients. For an old and established practice, more patients visit and therefore you can charge/claim more for each service rendered on each patient.

Specialty of Practice

If you are a specialist and you usually are referred many patients by other providers as per your network then FFS is a better arrangement. It is because usually specialists’ each and every procedure or treatment is expensive. For example you perform a procedure on a patient which costs $1500 then being able to receive payment against each $1500 treatment is better. In fact in such scenario FFS is the only recommended option.

If you are a family medical practice and you usually refer to other physicians for specialized treatments then capitation is better arrangement.

Finances Handling

Generally speaking, the frequency of payments in FFS arrangement is higher than capitation because as mentioned above, in capitation you receive only one lump sum check while if your treatments or procedures are high in quantity then frequency of payments through checks is comparatively higher in FFS. So if you have someone who can handle your finances then FFS is feasible. IF you don’t have anyone then don’t worry, our billers will take care of your payment posting.

Conclusion

The business of a billing company is linked with stability and collection of your practice. If your collections are unstable or uncertain then your liability towards your billing company should accordingly be less but each billing company has some fixed costs associated with your practice and if their fixed costs are more than the revenue that they make from your practice’s account then billing companies might start paying less attention to your account by assigning less costly, or in other words, less experienced labor or billers on your account. But with MED Xpert Services that’s not the case. We all the time keep an eye on all parameters of your contractual arrangements with the payers and timely advise you on maximizing your income.

The risk of low or no payment from patient cannot be avoided even if you try the best of the best billing practices but sometimes, even the best tools or teams cannot help you recover the billed amount from a patient. It can affect the image of your business as well. So carefully analyzing their plans is more important and far better than expecting them to pay up sometime later after being billed.

There are some specialties like therapists and dermatologists who see most of the patients less often. Skin treatment and therapy is something which is essential but at the same time costly for most of the people. In regards to how many times you see one patient, it is important to carefully take a look at his/her plan. Well who would do that? Well, that’s where you need us.

For instance, let’s take a look at a case of an insurance called Geico which, before reimbursing or making any payment analyses the patient carefully through their own designated provider who determines if a patient actually and really needed a certain treatment. What would happen if some such insurance denies your claims stating that your patient didn’t actually need any services you rendered. Your time and money both wasted. This can happen to therapists and dermatologists.

Some insurances have very long payment cycles and if that is the case then loss of money is indefinite. So what is the right way of looking into it? For specialists who have a lengthy or expensive procedure to perform on a patient, they need to analyze patient’s plan.

Generally speaking, PPO, or Preferred Provider Organization plan holders tend to have stronger financial position and they usually pay high in premiums and out-of-pocket expenses. For such patients, the chances of losing money or writing off an unrecoverable claims are less. Other plan holders can also come through if they have multiple insurances at their disposal.

Empire BCBS is a leading insurance company and it has multiple plans as per the needs of its patients. One of its plan is called EPO INN COSTSHARE IN PRIORITY. As the name suggests that this is an EPO based plan. Before diving deep into the discussion, let’s learn what EPO plans are.

“An EPO, or Exclusive Provider Organization plan, is a type of insurance plan in which patient can enjoy the flexibility of visiting any provider without needing to have prior approval or referral from another provider. So in simple words patient is not required to have any PCP locked in plan but that PCP also needs to be in network with patient’s plan.”

So based on above definition, if you someday, as a provider, see a patient who has such a plan and he gets some very expensive treatment from you in which you already are a specialist. Of course once a patient steps in, you might not be able to say NO to him. Now you treat him/her and done. You send the bill to your (other regular) billing company which as is sends the bill to insurance. But surprisingly insurance denies the claim stating that member has EPO plan and you, as a provider, are not in his network and hence no payment will be made. Your ordinary billing company sends the bill to patient but patient denies paying anything.

Above scenario can very much happen with specialists like therapists and skin specialists. Patient needed a laser treatment and you treated him/her but without taking a look into her/his plan. Now patient’s need has been met and it is less likely he/she might ever return.

Now your time and money both have been wasted. Your patient is also never going to come back to you because he/she wants to avoid making the payment to you.

If you use our billing services, we make sure that you are enrolled in all plans as per your community right at the time of singing up. Our professional team also recommends you what best suits you but in such a situation, we enroll you into that plan so that insurance does make the payment.

Is it as simple as that? No there are many leaps and bounds before deciding what the right way of recovering the payment is. We could send the reminders to the patients but why would patient come back for a treatment that he/she is planning to discontinue.

It happens a lot that patients have their insurance plans inactive but they are found unaware of it later on. Such patients, due to lack of coverage at the time of service, are billed and they usually get surprised and sometimes really angry upon receiving an unexpected bill.

In such scenario there is no way to bill insurance. In this scenario, only one thing works and that is the art of handling the customer. A patient is a customer for us. And our medical billing practices have been designed to keep the biller informed of expected patient’s reaction. Each action of a biller leads to some expected reaction and we tell him in our training manuals. So embed the patient’s perspective in the mind of biller and that works well in the interests of both the provider and patient but sometimes, things may go unexpected. Sometimes a patient would be shouting just upon a bill of a nominal amount and other times, he/she would be smiling while paying a bill with three digits before decimal.

What is the best way of handling someone who is over the phone? Our training manuals and hiring criteria rotate around hiring such a diversified and problem solver biller who would know the best course of action with minimal or no supervision. He/she will decide, if not right at the spot, but with clear understanding what suits best for the provider and how to convince the patient.

Sometimes, patient abuses. In such case, a rich experience in customer services and a clam personality comes in handy. When we say we do billing from patient’s perspective then that phenomenon speaks for itself when biller essentially tries all options and even after applying all options, if patient does not agree to pay then… we take care of the rest.

Our billers talk on your behalf. When patients receive bill they usually have problems with different perspectives but their all concerns in the end melt down to one thing, a smile, a nice gesture of friendship and concern and some best practices followed by the golden rules of professional judgment, prudence decision making and in the execution while keeping the provider’s instructions in mind.

Here at MED Xpert Services, we don’t compromise on essential qualities of a biller. The lifeline of our business rotates around behavior of a biller. Others hire them just for billing but we hire them and train them in all important aspects of business.

Internal and external communication with responsibility and entrepreneurship in handling every new or unexpected situation, remaining calm, eating good and living healthy and keeping a balance between life, family and work are part of our training materials and it is not hard for us, not at all. It looks complicated but our best practices handle every complication very calmly because our rules of engagement rotate around that perception of understanding others and remaining prepared for any unexpected situation.

A biller will never call him or herself a perfect biller. Because every situation has its own leaps and bounds and learning continuously is the name of the game. Many times when our billers run into a problem, like figuring out what would be the most suitable CPT to match with a Dx code lying in a long list of diagnosis, he is expected to perform some certain best practices that we teach them and they work very well.

Essentially our biller is motivated, focused, analytic, problem solver and open communicator. Many times, he/she is expected to think out of the box. Having grip in all types of communications in a must. Overall a clam person can become a good biller.