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  • Podiatry > Reimbursement Calculations

    NOTE: The examples hereunder are for illustrative purposes only. Actual numbers will differ and will vary by month.

    Determination of the Professional Podiatry Care Fund Amount

    Each month, EmblemHealth determines the amount of the Professional Podiatry Care Fund (PPCF) for all lines of business based on a number of financial variables.

    Current Month Pool Funding

    Medicare Budget

    $2.40

    Number of Enrollees

    50,000

    Gross Fund Amount (Monthly)

    $120,000

    Deductions from Fund (Illustrative Only)


    - Non-Par*

    $15,000

    Total Deductions

    $15,000



    Current Month Net Available for Distribution

    $105,000

    * Services provided by non-participating podiatrists will be deducted from the Market Share Payment pool.

    Determination of the Market Share Payment Value

    Market Share Payment values are determined by the historical average costs for all unique patient cases within a specialty. Adjustments may be made to the average case cost for fee-for-service exclusions and other situations. For example:

    $2,200,000

    Annual Total Podiatry Cost

    $500,000

    Nonparticipating Provider Costs

    $500,000

    Other Medical Costs

    $1,200,000

    Net Annual Historical Podiatry Costs

    * Illustrative Only

    If there were 12,000 unique patient cases reported by all podiatry providers in the previous 12 months, then the average patient case would cost $100 ($1.2M divided by 12,000 cases).

    Note: The Net Annual Historical Podiatry Cost and number of unique patient cases (reported by all practitioners) are calculated on a 12-month rolling average basis. As such, the average patient case cost (in this example, $100) will go up or down depending on the cost and case activity of the previous rolling 12 months. Any differences in the patient case cost will be reflected as an adjustment to the next month's payment.

    Determination of Individual Physician Payment

    For illustration purposes:

    1. Each month, a point is assigned to the podiatrist each time a unique patient is seen by the podiatrist. In January, Dr. Health saw three new patients.
      3 New Patient Cases = 3 Points for Dr. Health
      1,000 New Patient Cases for all participating podiatrists during the month of January
    2. Each month, EmblemHealth determines the amount of the Professional Podiatry Care Fund (PPCF) for all lines of business. For this example, let's say the pool has been allocated $100,000 in January.
    3. The amount paid to the podiatrist each month is based on the practitioner's individual points divided by the total points of all practitioners and multiplied by the available dollars in the pool. Dr. Health's payment for January would look something like this:

    Practitioner's Points

    /

    Total Points (All Practitioners)

    x

    Total Pool

    =

    Total Practitioner Payment

    3

    /

    1,000

    x

    $100,000

    =

    $300 Total Market Share Payment

    In months where the practitioner serves unique patients in addition to previously treated patients, the payment structure may look something like this. For example, let's say Dr. Health takes on one new case in February while still treating his three January patients:

    February

    January

    February

    Period-to-Date

    (1) Total Pool

    $100,000

    $100,000

    $200,000

    (2) New Patient Cases (All Practitioners)

    1,000

    950

    1,950

    (3) Dr. Health's New Patient Cases

    3

    1

    4

    (4) Market Share Payment Value

    $100

    $105.26

    $102.63 (avg to date)

    Practitioner

    Patient

    (a)
    January Points

    (b)
    New February Points

    (c)
    Period-to-Date Points (=a+b)

    (d)
    Period-to-Date Patient Value (=4, average)

    (e)
    Compensation through Prior Period*

    (f)
    Net Due February (=d-e)

    Dr. Health

    Patient 1

    1.0

    0.0

    1.0

    $102.63

    $100.00

    $2.63

    Patient 2

    0.0

    1.0

    1.0

    $102.63

    $0.00

    $102.63

    Patient 3

    1.0

    0.0

    1.0

    $102.63

    $100.00

    $2.63

    Patient 4

    1.0

    0.0

    1.0

    $102.63

    $100.00

    $2.63

    Total Dr. H

    3.0

    1.0

    4.0

    $410.52

    $300.00

    $110.52

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    Glossary terms found on this page:

    An individual who is enrolled and eligible for coverage under a health plan contract. Also called a member.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    Specific conditions or circumstances that are not covered under the benefit agreement or Certificate of Insurance. It is very important to consult the benefit contract to understand what services are not covered benefits.

    A payment method in which the insurer will reimburse the member or provider directly for each covered medical expense.

    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A participating provider is a member of the EmblemHealth network of providers applicable to the member's certificate. Therefore, they are more commonly referred to as network providers. Payment is made directly to a participating provider. Please consult the EmblemHealth Directory or go online to search for participating providers.

    A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

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