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.

Table 1. Default Time Periods
Display Name Start Date End Date

Calendar Year 2018

2018-01-01

2018-12-31

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.

Table 2. Schedule Definition
Code Description Type

PERCENTAGE BASED RATES

Payment percentage based rates

Rate
Table 3. 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.

Table 4. 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.

Table 5. Rate Schedule
Code Schedule Definition Amount Interpretation Currency

MEMBER PAYMENT AMOUNTS

PERCENTAGE BASED RATES

Contract Calculation Period

$
Table 6. 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.

Table 7. Schedule Definition
Code Description Type

MIN AM BASED

Minimum amount based adjustments

Adjustment
Table 8. 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.

Table 9. 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.

Table 10. Adjustment Schedule
Code Schedule Definition Adjust. Type

MINIMUM AMOUNT ADJUSTMENT

MIN AM BASED

Contract
Table 11. 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.

Table 12. 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.

Table 13. Contract Calculation Periods
Start Date End Date

2018-01-01

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

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.

Table 14. 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.

Table 15. Contract Time Periods
Display Name Start Date End Date

Contract Year 2018

2018-01-01

2018-12-31

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.

Table 16. 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.

Table 17. Contract Rate Splits
Split Level

All
Table 18. 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.

Table 19. 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.

Table 20. Contract Alignments
Member Payment Amount Start Date End Date

John Smith

10.00 $

2018-01-01

2018-12-31

Alice Jones

8.00 $

2018-01-01

2018-12-31

Members

The members that are aligned to the contract have specific characteristics which are important in the context of this contract.

Table 21. Members
Name Code Date of Birth Assigned Providers

John Smith

M631893

1984-08-08

Rodrigo Martinez (PCP from 2015-01-01)

Alice Jones

M259012

1951-10-06

Michael Lawrence (PCP from 2014-01-01)

Providers

The providers that are assigned to the above specified members have specific characteristics which are important in the context of this contract.

Table 22. Providers
Name Code Provider Group

Rodrigo Martinez

P10654

PCP PROVIDERS (from 2015-01-01)

Michael Lawrence

P33421

PCP PROVIDERS (from 2013-01-01)

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.

Table 23. Attributions
Member Calc. Period Start Date End Date

John Smith

January 2018

2018-01-01

2018-01-31

Alice Jones

January 2018

2018-01-01

2018-01-31

Calculation Results

For every attribution a calculation result with calculation result lines is created, based on the configured rate and adjustment schedules.

Table 24. Calculation Results
Member Calc. Period Attr. Start Date Rate Adj. Result Vers. Rev.

John Smith

January 2018

2018-01-01

8.50 $

0.00 $

8.50 $

1

N

Alice Jones

January 2018

2018-01-01

6.80 $

0.20 $

7.00 $

1

N

The calculation result lines are created per rate/adjustment component.

Table 25. Calculation Result Lines
Calculation Result Seq. Schedule Am. Inter. Retr. Value Input Am. Result

John Smith - January 2018 (2018-01-01) - V1

1

MEMBER PAYMENT AMOUNTS

CCP

8.50 $

8.50 $

John Smith - January 2018 (2018-01-01) - V1

2

MINIMUM AMOUNT ADJUSTMENT

CCP

0.00 $

8.50 $

0.00 $

Alice Jones - January 2018 (2018-01-01) - V1

1

MEMBER PAYMENT AMOUNTS

CCP

6.80 $

6.80 $

Alice Jones - January 2018 (2018-01-01) - V1

2

MINIMUM AMOUNT ADJUSTMENT

CCP

0.20 $

6.80 $

0.20 $

Financial Results

For every calculation result a base financial object is created.

Table 26. Base Financial Objects
Member Code Contract Code Calc. Period Start Date Attr. Start Date

M631893

MEDICARE ADVANTAGE

2018-01-01

2018-01-01

M259012

MEDICARE ADVANTAGE

2018-01-01

2018-01-01

For every base financial object a financial transaction is created.

Table 27. Financial Transactions
Base Financial Object Total Am. Rev. Vers.

M631893 - MEDICARE ADVANTAGE - January 2018 (2018-01-01)

8.50 $

N

1

M259012 - MEDICARE ADVANTAGE - January 2018 (2018-01-01)

7.00 $

N

1

The financial transaction details are created per rate/adjustment component.

Table 28. Financial Transaction Details
Financial Transaction Seq. Component Code Counterparty Code[1] Amount

M631893 - PCP CONTRACT - January 2018 (2018-01-01) - V1 - Reversed N

1

MEMBER PAYMENT AMOUNTS

ACCOUNT 1

1.11 $

M631893 - PCP CONTRACT - January 2018 (2018-01-01) - V1 - Reversed N

2

MEMBER PAYMENT AMOUNTS

ACCOUNT 2

4.42 $

M631893 - PCP CONTRACT - January 2018 (2018-01-01) - V1 - Reversed N

3

MEMBER PAYMENT AMOUNTS

ACCOUNT 3

1.27 $

M631893 - PCP CONTRACT - January 2018 (2018-01-01) - V1 - Reversed N

4

MEMBER PAYMENT AMOUNTS

PCP PROVIDERS

1.70 $

M631893 - PCP CONTRACT - January 2018 (2018-01-01) - V1 - Reversed N

5

MINIMUM AMOUNT ADJUSTMENT

ACCOUNT 1

0.00 $

M631893 - PCP CONTRACT - January 2018 (2018-01-01) - V1 - Reversed N

6

MINIMUM AMOUNT ADJUSTMENT

ACCOUNT 2

0.00 $

M631893 - PCP CONTRACT - January 2018 (2018-01-01) - V1 - Reversed N

7

MINIMUM AMOUNT ADJUSTMENT

ACCOUNT 3

0.00 $

M631893 - PCP CONTRACT - January 2018 (2018-01-01) - V1 - Reversed N

8

MINIMUM AMOUNT ADJUSTMENT

PCP PROVIDERS

0.00 $

M259012 - PCP CONTRACT - January 2018 (2018-01-01) - V1 - Reversed N

1

MEMBER PAYMENT AMOUNTS

ACCOUNT 1

0.88 $

M259012 - PCP CONTRACT - January 2018 (2018-01-01) - V1 - Reversed N

2

MEMBER PAYMENT AMOUNTS

ACCOUNT 2

3.54 $

M259012 - PCP CONTRACT - January 2018 (2018-01-01) - V1 - Reversed N

3

MEMBER PAYMENT AMOUNTS

ACCOUNT 3

1.02 $

M259012 - PCP CONTRACT - January 2018 (2018-01-01) - V1 - Reversed N

4

MEMBER PAYMENT AMOUNTS

PCP PROVIDERS

1.36 $

M259012 - PCP CONTRACT - January 2018 (2018-01-01) - V1 - Reversed N

5

MINIMUM AMOUNT ADJUSTMENT

ACCOUNT 1

0.03 $

M259012 - PCP CONTRACT - January 2018 (2018-01-01) - V1 - Reversed N

6

MINIMUM AMOUNT ADJUSTMENT

ACCOUNT 2

0.10 $

M259012 - PCP CONTRACT - January 2018 (2018-01-01) - V1 - Reversed N

7

MINIMUM AMOUNT ADJUSTMENT

ACCOUNT 3

0.03 $

M259012 - PCP CONTRACT - January 2018 (2018-01-01) - V1 - Reversed N

8

MINIMUM AMOUNT ADJUSTMENT

PCP PROVIDERS

0.04 $
1. The counterparty code is stored on the related financial transaction detail process data records