What reimbursement information should be provided in the in-network rate file when capitated payments are made to medical groups?

[ajmhardy]

To elaborate- when a plan makes capitated (PMPM) payments to a medical group, who then distributes these payments to their contracted individual providers based on the medical group's internal methodology, what information should be reported in the in-network rate file?

The final rule does state the following with respect to the self-service tool:
"...one commenter stated that issuers do not always have access to the negotiated rates or internal payment methodologies utilized by capitated medical groups or other providers and would not be able to reliably provide cost transparency based on a negotiated rate at the service level. "

The Final Rule goes on to say in the next paragraph:
"The Departments acknowledge that it is possible that some plans and issuers using alternative reimbursement models may not have negotiated rates or underlying fee schedule rates to disclose in the internet-based self-service tool. However, the numbers of plans and issuers without negotiated rates or underlying fee schedule rates is limited and the Departments are of
the view that an exemption for such arrangements is not necessary. Additionally, the Departments are of the view that providing an exemption for such arrangements will result in incomplete data sets. As stated in the final rules, the in-network rate must be disclosed, as applicable to the plan’s or issuer’s payment model. If the plan or issuer does not have negotiated
rates or underlying fee schedule rates, the third content element does not apply."

However, nothing specific is ever stated about capitated medical group reimbursement arrangements with respect to the in-network rate file. Does all this mean that providers paid via a capitated medical group are not considered to have a "negotiated rate", and that the plan would need to instead report a derived amount, if applicable?

Additionally, when a provider has multiple contracts with an issuer through multiple medical groups, how should this be handled?