Case Study: Capitation Management and Reporting
About Maui Medical Group
Maui Medical Group (MMG) is Hawaii’s largest multi-specialty medical group serving the people of Maui since 1961. With 80+ providers, nearly 340 employees and upwards of 40,000 patients as of 2021, MMG has grown with the needs of the Maui community.
In the last 20+ years, Bobbi Ranis, Manager of Provider Services and Cliff Alakai, CEO have navigated expanding reach with smart solutions and proactive troubleshooting.
Serving 5 locations
Kahului Office
Kihei Office
Lahaina Office
Pukalani Office
Wailuku Office
Modern updates require unique solutions
When MMG updated contracts with HMSA, their largest insurance carrier, revenue shifted to a new billing program called “Payment Transformation”, which is a capitated billing method. This created the need for an audit process, and the need to manage the new adjudication process.
What is Capitation?
Capitation is a billing method where a fixed amount is paid per patient, per unit of time to the physician for the delivery of services whether the patient seeks care or not.
The Problem
Approximately 60% of Maui Medical’s business is with HMSA, so the impact to the business was going to be very big. Moving to this capitated model and receiving a set payment regardless of the number of patients seen created distress regarding appropriate billing requirements:
How do we know we are getting the full PMPM fee that we should be getting based on the patients we are seeing? Is this being carefully calculated?
How are we best going to manage this program with over 25,000 attributed members to review each month?
How are we going to flag the patients for attribution forms, or let the staff know that the patient is already accounted for?
How are we going to account for HMSA members that are not yet patients of Maui Medical?
“If you can think it and write it on paper, a computer should be able to do it. Let’s call Open Practice and see if they can help.” – Cliff Alakai, CEO
The Solution
Working closely with Maui Medical, we developed and vigorously tested new functionality that would allow for a monthly upload of the insurance member data into OpenPM and new audit reports to detect and highlight possible discrepancies.
Test > Implement > Monitor results
“By the time we went live the data was pretty spot on because of the ongoing testing.” -Bobbi Ranis, Provider Services Manager.
Time and Money saved
Bobbi states that MMG would have hired a full time employee to manage this process, costing them $45-60,000 per year in salary alone. Not to mention the possible millions of dollars in errors and overpayments that could have been missed.
Speed Bump
More literal than you might think! There was an actual speed issue in the beginning, data was slow to load. But that was an easy resolution and now it’s perfectly fine.
“They gave us everything we wanted” – Cliff Alakai
Conclusion
“The new process is painless.” reports Bobbi. “Once we get the HMSA file, we import it, choose the dates and hit a button. It’s already mapped and formatted, and OpenPM kicks out any non-matching data.”
Building reports to cross-reference the insurance report with membership and adjudication records, created a simple and effective workflow that saves time, headaches and millions of dollars.
