For our clients that participate in capitation agreements, MSM offers claims adjudication and capitation distribution services to track encounter data and distribute contract funds. This is accomplished through:

Distribution Methodology
MSM has the ability to distribute revenue using a number of industry methods, including:

• Production Formulas
  • Health Plan Fee-For-Service (FFS) Equivalent Charges
  • Resource Based Relative Value Units
  
  
  • Service Points
  
  
  • Production Formulas with Benchmark Adjustment Factors


• Patient Encounter Formulas
• Contact Capitation


• Market Share


• Patient Encounter Formulas with Age-Sex or Case Mix Adjustments

Adjudication Guidlines
The use of current relational database technology allows MSM to employ claims adjudication guidelines developed internally by the IPA. These guidelines ensure provider fund distribution is congruent with IPA directives.

Utilization & Compensation Comparison Reports
MSM creates and maintains data warehouses for all clients who want to track utilization and compensation data closely. Advanced querying and reporting technologies enable our clients to assess utilization of services by:

• Service Category or Surgical Case Type


• Place of Service and/or Facility


• Medical Group and/or Individual Provider


• Diagnosis (ICD-9) and/or Procedure Code (CPT)


• Individual Referring Physician and/or Referring Physician Specialty

Utilization can be defined by:

• Number of Procedures Per 1000 Members Per Year


• Per Member Per Month (PMPM) with Comparisons to Reimbursement Benchmarks


• Ratios of Activity Within a Specific Service, Location or Entire Contract