Medical Insurance Expert Witnesses & Managed Care Part 2

Medical 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:

Other types of risk sharing include withholds, when a portion of the provider payment is held back and only paid later if certain criteria are met. Also, there are shared risk funds, where physician groups share in a portion of the financial risk and potential profit of hospital or prescription costs.

How shared risk funds work: Typically, in a shared risk arrangement, a fund gets “paid” the capitation rate. Medical expenses are paid from this fund, and periodically, profits or losses are distributed to the participants.

Shared risk funds often allocate the risk between physicians and institutional providers, or between physicians and health plans. Occasionally, there are three or more parties involved (Health Plan, Physicians, Hospital and a management company could all be involved). Hospital and Pharmacy services are the most prevalent examples of shared risk funds. However, there are many other types of services that involve shared risk arrangements as well.

For more, see