A contemporary perspective on capitated reimbursement for imaging services

Capitation ensures predictability of healthcare costs, requires acceptance of a premium in return for providing all required medical services and defines the actual dollar amount paid to a physician or hospital on a per member per month basis for a service or group of services. Capitation is expected to dramatically affect the marketplace in the near future, as private enterprise demands lower, more stable healthcare costs. Capitation requires detailed quantitative and financial data, including: eligibility and benefits determination, encounter processing, referral management, claims processing, case management, physician compensation, insurance management functions, outcomes reporting, performance management and cost accounting. It is important to understand actuarial risk and capitation marketing when considering a capitation contract. Also, capitated payment methodologies may vary to include modified fee-for-service, incentive pay, risk pool redistributions, merit, or a combination. Risk is directly related to the ability to predict utilization and unit cost of imaging services provided to a specific insured population. In capitated environments, radiologists will have even less control over referrals than they have today and will serve many more "covered lives"; long-term relationships with referring physicians will continue to evaporate; and services will be provided under exclusive, multi-year contracts. In addition to intensified use of technology for image transfer, telecommunications and sophisticated data processing and tracking systems, imaging departments must continue to provide the greatest amount of appropriate diagnostic information in a timely fashion at the lowest feasible cost and risk to the patient.