Scenario 2
In this capitation scenario a payment arrangement for calendar year 2018 is made between the healthcare payer and primary care providers that are part of a specific provider network (provider group). The provider group is paid (part of) a monthly rate amount (a minimum amount is guaranteed) per attributed member. This rate amount is calculated based on a percentage of the member payment amount provided in the member data. The payment is split between the provider group and multiple other accounts.
Configuration
In the sections below the default time periods, rates, adjustments and capitation contract that are needed for the above specified scenario are described.
Default Time Periods
The payment arrangement is made for calendar year 2018, so a default time period is configured for calendar year 2018. The rates and adjustments that are specified in the sections below are in the context of this default time period.
Default Time Periods
| Display Name | Start Date | End Date |
|---|---|---|
Calendar Year 2018 |
01-01-2018 |
12-31-2018 |
Rates
The base rate amount that is paid per member is based on a payment percentage, so a schedule definition with a payment percentage dimension is configured.
Schedule Definition
| Code | Description | Type |
|---|---|---|
PERCENTAGE BASED RATES |
Payment percentage based rates |
Rate |
Schedule Dimensions
| Display Name | Field Name | Type | Usage |
|---|---|---|---|
Payment Percentage |
paymentPercentage |
Generic (nr) |
Value |
To fetch the payment amount from the member information and calculate a percentage of it, a dynamic logic function with signature Rate is configured.
Dynamic Logic
| Code | Signature | Logic |
|---|---|---|
MEMBER PAYMENT AMOUNT |
Rate |
def contractAlignments = attribution.person.contractAllignmentList.asOf(referenceDate) for contractAlignment in contractAlignments( if (contractAlignment.capitationContract.code == attribution.contractCalculationPeriod.capitationContract.code) return Money.create(contractAlignment.paymentAmount).percentage(rateScheduleLine.paymentPercentage) ) |
A rate schedule is configured with rate schedule lines for the default time period "Calendar Year 2018", based on the above specified schedule definition.
Rate Schedule
| Code | Schedule Definition | Amount Interpretation | Currency |
|---|---|---|---|
MEMBER PAYMENT AMOUNTS |
PERCENTAGE BASED RATES |
Contract Calculation Period |
$ |
Rate Schedule Lines
| Payment Percentage | Rate |
|---|---|
85 |
MEMBER PAYMENT AMOUNT |
Adjustments
A minimum amount adjustment applies to the base rate amount. This means that the provider group is paid a minimum amount per member as an income guarantee, so a schedule definition with a dimension for minimum amount is configured.
Schedule Definition
| Code | Description | Type |
|---|---|---|
MIN AM BASED |
Minimum amount based adjustments |
Adjustment |
Schedule Dimensions
| Display Name | Field Name | Type | Usage |
|---|---|---|---|
Minimum Amount |
minimumAmount |
Generic (amount) |
Value |
To compare the rate amount with the minimum amount, a dynamic logic function with signature Adjustment is configured.
Dynamic Logic
| Code | Signature | Logic |
|---|---|---|
MINIMUM AMOUNT |
Adjustment |
if amount >= adjustmentScheduleLine.minimumAmount return Money.create(0) else return adjustmentScheduleLine.minimumAmount - amount |
An adjustment schedule is configured with adjustment schedule lines fordefault time period "Calendar Year 2018", based on the above specified scheduledefinition. This adjustment only applies to specific contracts so the adjustmenttype is set to Contract.
Adjustment Schedule
| Code | Schedule Definition | Adjust. Type |
|---|---|---|
MINIMUM AMOUNT ADJUSTMENT |
MIN AM BASED |
Contract |
Adjustment Schedule Lines
| Minimum Amount | Adjustment |
|---|---|
7.00 $ |
MINIMUM AMOUNT |
Capitation Contract
A capitation contract is configured that uses the MEMBER PAYMENT AMOUNTS rate schedule. Payment is made to the provider group (specified as a dynamic field on the contract), so the attribution type of the contract is set to Member.
Capitation Contracts
| Code | Description | Attribution Type | Rate Schedule | Provider Group |
|---|---|---|---|---|
PCP CONTRACT |
Primary Care Providers Contract |
Member |
MEMBER PAYMENT AMOUNTS |
PCP PROVIDERS |
In the sections below the contract calculation periods, contract provider filter rules, contract adjustments, contract rate splits and dynamic logic that are part of this contract are described.
Contract Calculation Periods
Payments are made monthly so for each month in 2018 a contract calculation period is configured.
Contract Calculation Periods
| Start Date | End Date |
|---|---|
01-01-2018 |
01-31-2018 |
02-01-2018 |
02-28-2018 |
03-01-2018 |
03-31-2018 |
04-01-2018 |
04-30-2018 |
05-01-2018 |
05-31-2018 |
06-01-2018 |
06-30-2018 |
07-01-2018 |
07-31-2018 |
08-01-2018 |
08-31-2018 |
09-01-2018 |
09-30-2018 |
10-01-2018 |
10-31-2018 |
11-01-2018 |
11-30-2018 |
12-01-2018 |
12-31-2018 |
Contract Provider Filter Rules
The contract only applies to primary care providers that are in the PCP PROVIDERS network, so a contract provider filter rule is configured with a PCP provider assignment type and a PCP PROVIDERS provider group.
Contract Provider Filter Rules
| Sequence | Provider Assignment Type | Provider Group |
|---|---|---|
1 |
PCP |
PCP PROVIDERS |
Contract Adjustments
The adjustment schedules of adjustment type Contract are added to contracts in the context of contract time periods, so a contract time period for calendar year 2018 is configured.
Contract Time Periods
| Display Name | Start Date | End Date |
|---|---|---|
Contract Year 2018 |
01-01-2018 |
12-31-2018 |
The minimum amount adjustment is added to the contract in the context of the above configured contract time period. It applies to the base rate amount, so the sequence is set to 1.
Contract Adjustments
| Contract Time Period | Adjustment Schedule | Sequence |
|---|---|---|
Contract Year 2018 |
MINIMUM AMOUNT ADJUSTMENT |
1 |
Contract Rate Splits
The result amount is split up between different accounts and the provider group, so a rate split with a number of payment receivers is set up.
Contract Rate Splits
| Split Level |
|---|
All |
Contract Payment Receivers
| Contract Rate Split | Percentage | Payment Receiver Function |
|---|---|---|
All |
13 % |
PR ACCOUNT 1 |
All |
52 % |
PR ACCOUNT 2 |
All |
15 % |
PR ACCOUNT 3 |
All |
20 % |
PR PROVIDER GROUP |
Dynamic Logic
The dynamic logic functions that are used within the contract are configured as specified below.
Dynamic Logic
| Code | Signature | Logic |
|---|---|---|
PR ACCOUNT 1 |
Payment Receiver |
return 'ACCOUNT 1' |
PR ACCOUNT 2 |
Payment Receiver |
return 'ACCOUNT 2' |
PR ACCOUNT 3 |
Payment Receiver |
return 'ACCOUNT 3' |
PR PROVIDER GROUP |
Payment Receiver |
return contractPaymentReceiver.contractRateSplit.capitationContract.providerGroup |
FT SET GROUPING |
Financial Transaction |
financialTransaction.financialTransactionProcessData.finTransactionSetGrouping = calculationResult.contractCalculationPeriod.capitationContract.code return financialTransaction |
Contract Alignments
A subset of the contract alignments, members and providers that are in the context of this contract are specified in the sections below.
Alignments
In the table below a number of contract alignments that apply to the contract are specified.
Contract Alignments
| Member | Payment Amount | Start Date | End Date |
|---|---|---|---|
John Smith |
10.00 $ |
01-01-2018 |
12-31-2018 |
Alice Jones |
8.00 $ |
01-01-2018 |
12-31-2018 |
Members
The members that are aligned to the contract have specific characteristics which are important in the context of this contract.
Members
| Name | Code | Date of Birth | Assigned Providers |
|---|---|---|---|
John Smith |
M631893 |
08-08-1984 |
Rodrigo Martinez (PCP from 01-01-2015) |
Alice Jones |
M259012 |
10-06-1951 |
Michael Lawrence (PCP from 01-01-2014) |
Providers
The providers that are assigned to the above specified members have specific characteristics which are important in the context of this contract.
Providers
| Name | Code | Provider Group |
|---|---|---|
Rodrigo Martinez |
P10654 |
PCP PROVIDERS (from 01-01-2015) |
Michael Lawrence |
P33421 |
PCP PROVIDERS (from 01-01-2013) |
Calculation
When the Capitation Calculation activity is run for the contract with a calculation input date in January 2018, a number of attributions, calculation results and financial results are created based on the contract alignments and the configuration of the contract.
Attributions
A number of attributions are created in the context of the contract alignments that are specified above.
Attributions
| Member | Calc. Period | Start Date | End Date |
|---|---|---|---|
John Smith |
January 2018 |
01-01-2018 |
01-31-2018 |
Alice Jones |
January 2018 |
01-01-2018 |
01-31-2018 |
Calculation Results
For every attribution a calculation result with calculation result lines is created, based on the configured rate and adjustment schedules.
Calculation Results
| Member | Calc. Period | Attr. Start Date | Rate | Adj. | Result | Vers. | Rev. |
|---|---|---|---|---|---|---|---|
John Smith |
January 2018 |
01-01-2018 |
8.50 $ |
0.00 $ |
8.50 $ |
1 |
N |
Alice Jones |
January 2018 |
01-01-2018 |
6.80 $ |
0.20 $ |
7.00 $ |
1 |
N |
The calculation result lines are created per rate/adjustment component.
Calculation Result Lines
| Calculation Result | Seq. | Schedule | Am. Inter. | Retr. Value | Input Am. | Result |
|---|---|---|---|---|---|---|
John Smith - January 2018 (01-01-2018) - V1 |
1 |
MEMBER PAYMENT AMOUNTS |
CCP |
8.50 $ |
8.50 $ |
|
John Smith - January 2018 (01-01-2018) - V1 |
2 |
MINIMUM AMOUNT ADJUSTMENT |
CCP |
0.00 $ |
8.50 $ |
0.00 $ |
Alice Jones - January 2018 (01-01-2018) - V1 |
1 |
MEMBER PAYMENT AMOUNTS |
CCP |
6.80 $ |
6.80 $ |
|
Alice Jones - January 2018 (01-01-2018) - V1 |
2 |
MINIMUM AMOUNT ADJUSTMENT |
CCP |
0.20 $ |
6.80 $ |
0.20 $ |
Financial Results
For every calculation result a base financial object is created.
Base Financial Objects
| Member Code | Contract Code | Calc. Period Start Date | Attr. Start Date |
|---|---|---|---|
M631893 |
MEDICARE ADVANTAGE |
01-01-2018 |
01-01-2018 |
M259012 |
MEDICARE ADVANTAGE |
01-01-2018 |
01-01-2018 |
For every base financial object a financial transaction is created.
Financial Transactions
| Base Financial Object | Total Am. | Rev. | Vers. |
|---|---|---|---|
M631893 - MEDICARE ADVANTAGE - January 2018 (01-01-2018) |
8.50 $ |
N |
1 |
M259012 - MEDICARE ADVANTAGE - January 2018 (01-01-2018) |
7.00 $ |
N |
1 |
The financial transaction details are created per rate/adjustment component.
Financial Transaction Details
| Financial Transaction | Seq. | Component Code | Counterparty Code [1] | Amount |
|---|---|---|---|---|
M631893 - PCP CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
1 |
MEMBER PAYMENT AMOUNTS |
ACCOUNT 1 |
1.11 $ |
M631893 - PCP CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
2 |
MEMBER PAYMENT AMOUNTS |
ACCOUNT 2 |
4.42 $ |
M631893 - PCP CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
3 |
MEMBER PAYMENT AMOUNTS |
ACCOUNT 3 |
1.27 $ |
M631893 - PCP CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
4 |
MEMBER PAYMENT AMOUNTS |
PCP PROVIDERS |
1.70 $ |
M631893 - PCP CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
5 |
MINIMUM AMOUNT ADJUSTMENT |
ACCOUNT 1 |
0.00 $ |
M631893 - PCP CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
6 |
MINIMUM AMOUNT ADJUSTMENT |
ACCOUNT 2 |
0.00 $ |
M631893 - PCP CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
7 |
MINIMUM AMOUNT ADJUSTMENT |
ACCOUNT 3 |
0.00 $ |
M631893 - PCP CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
8 |
MINIMUM AMOUNT ADJUSTMENT |
PCP PROVIDERS |
0.00 $ |
M259012 - PCP CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
1 |
MEMBER PAYMENT AMOUNTS |
ACCOUNT 1 |
0.88 $ |
M259012 - PCP CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
2 |
MEMBER PAYMENT AMOUNTS |
ACCOUNT 2 |
3.54 $ |
M259012 - PCP CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
3 |
MEMBER PAYMENT AMOUNTS |
ACCOUNT 3 |
1.02 $ |
M259012 - PCP CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
4 |
MEMBER PAYMENT AMOUNTS |
PCP PROVIDERS |
1.36 $ |
M259012 - PCP CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
5 |
MINIMUM AMOUNT ADJUSTMENT |
ACCOUNT 1 |
0.03 $ |
M259012 - PCP CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
6 |
MINIMUM AMOUNT ADJUSTMENT |
ACCOUNT 2 |
0.10 $ |
M259012 - PCP CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
7 |
MINIMUM AMOUNT ADJUSTMENT |
ACCOUNT 3 |
0.03 $ |
M259012 - PCP CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
8 |
MINIMUM AMOUNT ADJUSTMENT |
PCP PROVIDERS |
0.04 $ |