Handling capitation with percent of billed

[PricedTransparently]

It is possible for a contract to have a pay method of "percent of billed", with a service type of "Capitated". In this scenario, we would have a negotiation_arrangement of "capitation" and a negotiated_type of "derived". The problem here is that our negotiated_rate would be a percentage value (not a dollar amount), but there is nothing in the schema that conveys this information. How should we be handling this scenario? Should we be making use of the additional_information object for this?

[shaselton-usds]

@PricedTransparently I just want to check that your understanding of "derived" falls inline with the rule's definition.

It would seem that "derived" would be a dollar amount vs a percentage.

You can certainly report a negotiation_arrangement as "capitation" and the negotiation_type as "percentage" if that is what you have. Also, note that negotiated_prices is an array to allow for multiple reporting of negotiation types -- so you may report a percentage as well as a derived amount if those are different.

[bryanbriegel]

The TiC rule calls for a dollar amount to be disclosed in the in-network negotiated rate files, and there is no allotment for reporting a percentage that I can see. "the final rules clarify that plans and issuers are required to include for each item or service in the In-network Rate File, the base negotiated rate that applies before adjusting for participant, beneficiary, or enrollee -specific characteristics. The negotiated rate in the referenced-based pricing model must be represented as a dollar value that is the result of the calculation of the referenced amount and the applicable reference-based percentage" this aligns with the PRA packet, which also requires a dollar amount (not percentage) to be disclosed: "the negotiated rate, reflected as a dollar amount, for each covered item or service under the plan or coverage that the plan or issuer has contractually agreed to pay an in-network provider,.."