Hi! Does anyone have experience in the full-risk capitated value-based care model? I’m wondering how the reimbursement works if spending exceeds the allowance. For example, if the provider orders a test and it’s not covered, does the practice get penalized past a certain amount? Thanks in advance!

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I’ll assume it’s Medicare Advantage. If you’re coding appropriately, reimbursement is never going to be an issue at the single test level. Use fairly-priced lab and imaging services. Stay away from hospital-based services unless you’ve negotiated a favorable rate. Ultimately, Admissions drive profitability. Work to encourage patients to choose fairly priced hospitals. Do what you can to avoid inappropriate or avoidable admissions. But accept admissions when appropriate (i.e. don’t ‘block’). There are stop-loss safety thresholds in place for the really expensive ones, which should be the direct answer to your question. The lawsuit costs for blocking one appropriate admission will wipe out any savings you could’ve hoped to gain.

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Thanks for your input!

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