The provider contract that Dr. Zachery Cogan, an internist, has with the Neptune Health Plan calls for Neptune to reimburse him under a typical PCP capitation arrangement. Dr. Cogan serves as the PCP for Evelyn Pfeiffer, a Neptune plan member. After hospitalizing Ms. Pfeiffer and ordering several expensive diagnostic tests to determine her condition, Dr. Cogan referred her to a specialist for further treatment. In this situation, the compensation that Dr. Cogan receives under the PCP capitation arrangement most likely includes Neptune's payment for

Question

Quizplus · Accepted Answer

Under a PCP capitation arrangement, the primary care physician (PCP) is paid a fixed amount per patient to manage and coordinate their care. This payment is usually determined regardless of the number or types of diagnostic tests or treatments that the patient may require. Therefore, the compensation that Dr. Cogan receives under the capitation arrangement most likely includes Neptune's payment for his visits to Ms. Pfeiffer while she was hospitalized, as these visits are part of his overall management and coordination of her care as her PCP. The cost of the services that the specialist performed for Ms. Pfeiffer would not be included in Dr. Cogan's capitation payment, as he referred her to the specialist for further treatment that is outside the scope of his PCP role. The payment for the diagnostic tests that Dr. Cogan ordered on Ms. Pfeiffer would depend on whether they were performed in his office or at an outside facility and could be covered under different payment arrangements, such as fee-for-service or bundled payments.

The Provider Contract That Dr