Following HCFA rules eases head count woes
Inaccurate member counts can cost you big bucks
Fundamental to ensuring you are not getting shortchanged out of the payments specified in your capitation contract is to make sure the member count used to determine payments is accurate. However, capitation contracts often cover thousands of lives with members moving in and out of the plan every day, making it difficult to maintain an accurate count.
One way to audit this enrollment data is to use the rules devised by the Health Care Financing Administration (HCFA) to verify Medicare HMO enrollment that went into effect last January. Under HCFA’s guidelines:
• Completed elections (i.e., enrollments and disenrollments) made on or before the 10th day of the month are effective the first day of the first calendar month following the date the election is made.
• Elections made after the 10th day of each month are effective the first day of the second calendar month after the election is made.
• An election is made only when it is received by the insurer and completed.
To illustrate, according to HCFA:
• If a completed enrollment form is received
by the managed care insurer on May 10, 2000, the effective date is June 1, 2000. If that same completed enrollment form were to be received on May 11, 2000, it would be effective on July 1, 2000.
• If a completed written request to disenroll is received by the managed care insurer on July 8, 2000, the effective date is Aug. 1, 2000. If that same written request were to be received on July 20, 2000, the effective date would be Sept. 1, 2000.
• If an insurer receives a completed enrollment form on May 2, then the effective date of the enrollment is June 1. The insurer has up to 30 days from May 2 to submit the transaction. But submission of the transaction prior to the May systems’ cutoff date will ensure more timely payment for the June 1 effective date.
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