Tools include authorization requirements to approve services before they occur, concurrent review for continuing cases, and profiling of cases after they occur for analysis. Demand Management A program administered by MCOs or provider organizations to monitor and process many types of initial member requests for clinical information and services. The program may involve operating an extended hours nursing telephone triage service for members, or patient education materials and resources. In paying providers, capitation and salaries involve the highest levels of provider risk, and are usually just allowed under HMOs. Per Case payments also involve some risk, as costs could exceed the case payment.
Providers are at full financial risk for the services capitated.
The provider is paid a fixed amount per member enrolled, regardless of the number of services delivered to that member. Contact capitation is a relatively newer capitation methodology based on experience. Under a contact capitation arrangement, the managed care organization typically pays a provider a capitated amount per qualifying patient, as opposed to an entire member population. There are a number of alternative structures for contact capitation. Payments can be a global fee for entire episode of care, or it may be a monthly payment for the period of time that the patient is referred or has been diagnosed with a specific condition.