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Provider Payment Methodologies
Atlantis Health Plan participating Primary Care Providers and most Specialists are reimbursed on a discounted fee-for-service basis with a contingency reserve. This means that a physician is paid each time he or she provides a service to you. The contingency reserve is a percentage of the physician’s payment that is retained by Atlantis until the end of the year. Distribution of the contingency reserve to the participating physicians is based on the total cost of health care services compared to the amount projected based on the premium rate which was paid to Atlantis by your employer/Group. This contingency reserve protects Atlantis in the case that more services are provided to our Members than were projected. The contingency reserve encourages participating physicians to provide your health care services as efficiently as possible, but does not encourage your physician to withhold services as some other systems of reimbursement may.
Some network Specialists may be paid on a capitated basis. This means that a set dollar amount, per Member, per month, is paid to the Provider regardless of the type or number of actual services provided.
Most participating hospitals are paid on a per diem basis. This means that each day you are in the hospital, the hospital is paid a set amount for that day. In order to keep your premiums as reasonable as possible, Atlantis Health Plan monitors hospitalization closely. Atlantis also recognizes that while many extended hospitalizations are Medically Necessary, no one would prefer to be in a hospital rather than being at home. It is our desire to work in a partnership with you, your doctor and your hospital to optimize the length of your hospital stay.
Non-participating physicians are also reimbursed on a fee-for-service basis. In most instances, the fee is based on a payment schedule rather than a negotiated rate. These payment schedules are periodically updated to accurately reflect geographic differences. The fee schedule represents the Usual, Customary or Reasonable (UCR) charge for a medical service. When you use Out-of-Plan benefits, Atlantis will use the MDR fee schedule to determine the allowed amount for the service. With respect to surgical procedures, the schedule makes provision for:
(a) Allowed amounts for covered procedures not specifically listed in the schedule to be consistent with the benefits for comparable procedures;
(b) Multiple surgical procedures performed during the same operative session and through the same incision to be reimbursed in an amount not less than the allowed amount for the most expensive procedure then being performed;
(c) Multiple surgical procedures performed during the same operative session but through different incisions to be reimbursed in an amount not less than that for the most expensive procedure then being performed; and
(d) With regard to the less expensive procedure, payment will be in an amount at least equal to 50 percent of the scheduled amount for these procedures, unless a different amount is specifically set forth in the State of New York Certified Surgical Fee Schedule.
The MDR schedule amount for reimbursement of a particular elective surgical procedure or treatment is available to Members upon written request.