Question

Why is it important to distinguish between the billing provider and the pay-to provider in physician practices?

Answer 1

Ans) Billing provider: The person or organization sending a HIPAA claim, as distinct from the pay-to provider who receives payment.

Capitation in its simplest form is a payment a provider receives to cover all services for a specified population over a period of time. For example, a doctor's office has 100 patients, and they get paid $25 per month for each patient to cover all costs associated with those patients for the month.

- Four Payment Methods:

The four payment methods that health plans use to pay physicians are:

Fee-for-service - physicians are paid for every service and test that they provide based on the usual and customary charges of physicians in the local area.
Discounted fee-for-service - physicians are paid for every service and test they provide based on a fee schedule or pre-determined discount of the usual and customary price charged by physicians in the local area.
Capitation - physicians are paid a fixed amount per enrollee, not per service, on a monthly basis.
Salary - physicians are paid a fixed weekly or monthly amount, and pay is not tied to enrollees or services rendered.