Health Insurance Expert Witnesses & Managed Care Part 1

Health insurance expert witnesses may opine on health insurance, medical insurance, managed care, and more. In Managed Care Fact Sheets, experts at the health care publisher MCOL describe provider payment arrangements:

In Managed Care Organization (MCO) provider contracts, providers often bear some level of financial risk. In paying providers, capitation and salaries involve the highest levels of provider risk, and are usually just allowed under HMOs. Episode of Care payments also involve some risk, as costs could exceed the case payment.

Capitation: Capitation means paying a fixed amount of money per person (per capita). Capitation puts a lid on payments per person that otherwise might change under a fee-for-service system. Providers are at full financial risk for the services capitated. The provider is paid a fixed amount per member enrolled, regardless of the number of services delivered to that member.

Episode of Care: in which the managed care organization typically pays a provider a set amount per qualifying patient package price for a defined episode of care. There are a number of alternative structures for such payment arrangements.

For more, see