Capitation ( HMO / DMO ) Insurance Plan
Capitation is also known as HMO/DMO. Set up this Insurance Plan Type when you receive a flat fee every month, regardless of what work is done on the patients.
Patients pay a flat fee for some procedures and no fee for other procedures. Sometimes, a fee for the lab portion can be billed to insurance.
To set up a plan that has co-pays and makes supplemental payments (mixed capitation), seeHMO / DMO Insurance Plan with Co-pays instead.
If you need to bill insurance (rare)
Because the claim is for a capitation insurance plan, the amount expected from insurance will not be applied to the patient balance.
When you receive the monthly payment from the carrier, do not enter the payment in the claim. Instead, record the payment in a dummy patient for the carrier:
We do not recommend having more than one capitation plan for a single patient. If you do so, you must manually change the secondary capitation plan's write-off amounts for each procedure and Open Dental reports will give incorrect production numbers. To fix production numbers, run Query #911, then delete any duplicate CapCom status insurance estimates so that there is only one CapCom estimate for each procedure.
Also do not manually add insurance estimates with a CapCom status; they are created automatically. If you have duplicates, production numbers will be inaccurate. To fix production numbers, run Query #911, then delete any duplicate CapCom status insurance estimates so that there is only one CapCom estimate for each procedure.
Run the Capitation Utilization Report at the end of each month to show all procedures for a date range performed for capitation, along with the provider fees and the patient co-pay.
Production and Income Reports include production from capitation as Procedure Fee - Capitation Write-offs (as part of the (gross) Production column). For most procedures this contribution is $0, but if there is a patient portion (copay) then the capitation write-off will be less than the fee and thus the patient portion is part of the production.
Aging of Accounts Receivable (A/R) Report: Capitation payments entered under a dummy patient will reflect as credits in the A/R report. This can be avoided by using a billing type that is excluded when running the A/R report.
Internally, a capitation claim creates a second claim procedure.
Payment entry on individual capitation claims would be a feature request.