Capitation Payment, Billing/Encounter Submissions

Capitation Payment, Billing/Encounter Submissions

Capitation, Billing & Encounter File Submission, Payment Processing & Finance

This training will be focused on Capitation, Billing & Encounter File Submission, Payment Processing & Finance for the Capitated Preparedness Payment Project (CP3). The attendees will largely be clinics that have volunteered to participate as pilot sites. Based on requests from members we are now opening these June trainings up to the full CPCA membership. If your organization is participating in the pilot but perhaps not your site and you want to learn more about the pilot we encourage you to attend these trainings. If you just want to learn more about how processes and systems would change in an alternative payment model these trainings are for you. We would be thrilled to have you join your colleagues and the CP3 team as we learn from our content expert Curt Degenfelder.

Objectives. Participants will learn how to:
  1. Receive, process and manage capitation payments and cash flow
  2. Reconcile capitation payments with member rosters and eligibility files
  3. Generate, submit and reconcile encounter files
  4. Develop budgets, create forecasting models and track financial performance under capitated arrangements


Curriculum Description

  1. Managed care capitation overview:
    1. Services included and excluded under capitated arrangements, including primary care, behavioral health, alternative touches and other services
    2. Medi-Cal aid codes used in capitation arrangements
    3. Managed care membership assignment to clinic sites, and reassignment from one site to another
    4. Processing and managing capitation payments, and reconciling eligibility/membership files with capitation payments
  2. Managing claims and encounter files:
    1. Claims and encounter file submission overview, including process flows, considerations for clinic corporations with sites both in and out of the pilot, importance of file submission and reporting and what needs to be submitted, when, by whom and to whom
    2. Encounter file standards and non-standard coding issues
    3. Impact of EHR coding and documentation on encounter file submissions
    4. Working denied/rejected encounter file submissions
    5. Descriptions of what constitutes alternative touches, including telehealth, phone and e-mail consults, consultations with non-billing providers (e.g., peer health educators)
    6. Billing, documenting and reporting of alternative touches
  3. Budget forecasting and cash management:
    1. Understanding and accounting for changes in timing of PPS and wrap-around payments, and impact to clinic cash flow
    2. Developing and using dashboards to track financial performance under capitated arrangements
    3. Accounting for and managing financial impact of assigned and non-assigned members
    4. Forecasting, modeling and adjusting FTE counts to support team-based care at clinic sites
    5. Measuring and assessing cost of care for all members and patients, regardless of payer and contract arrangement
    6. Using internal service audits to identify errors and potential compliance issues
    7. Reviewing CP3 pilot risk corridor structure and implications

Suggested team member participants:  C Suite (CFO, CMO, COO), Finance, Operations, Billing, Coding

If you have any dietary restrictions, please email Charlotte Reische, at

6/13/2017 9:00 AM - 4:30 PM
St. Anne’s 155 N. Occidental Blvd. Los Angeles, CA 90026 UNITED STATES

Sign In to Register