HEALTHsuite®
Capitation Module
HEALTHsuite’s Capitation module enables health care organizations to reimburse providers automatically for capitated services. This highly sophisticated module establishes relationships between providers and allows payments to be spread across multiple providers for the same member.
The rules-based approach of the Capitation module allows health plans to support an unlimited number of user-defined methods of capitation including PMPM, percent of premium, flat amounts, age/sex criteria, risk of members, direct capitation and sub-capitation.
HEALTHsuite has the ability to pay providers under fee-for-service up to a specific panel size, then pay capitation. It can also capitate providers based upon the risk size of the provider’s panel (i.e. if a percentage of the panel is an elderly or HIV population, the health plan can capitate the provider more for the entire panel, based upon that percentage of the population).