The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline. Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumn's PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumn's dermatology services fund for the first quarter was $15,000. During the quarter, Autumn's PCPs made 90 referrals, and 20 of these referrals were classified as complicated. Autumn's method of reimbursing specialty providers can best be described as a
A) Disease-specific arrangement
B) Contact capitation arrangement
C) Risk adjustment arrangement
D) Withhold arrangement

Question

Quizplus · Accepted Answer

The method of reimbursing providers in Autumn's network involves a fixed pool of funds that is actuarially determined for each specialty. This aligns with a capitation arrangement, where providers are paid a set amount per member per period of time (in this case, per quarter) regardless of the number of services provided. The accumulation of points for new referrals made by Autumn's PCPs reinforces the capitation model by incentivizing providers to attract more patients to the network. The other options (disease-specific arrangement, risk adjustment arrangement, withhold arrangement) do not accurately describe this method of reimbursement.

The Method That the Autumn Health Plan Uses for Reimbursing