Q: Our institution has started to create a medical home delivery system. One of the health plans that is interested in this has offered a small PMPM payment to cover case management. How can we know if the plan’s offer is reasonable?
A: You should expect the PMPM to cover the salary and benefits of the case manager(s) required to handle the population. Typically, there is one case manager for a 10,000 population for commercial, and one for a 5,000 to 7,500 population for Medicaid and Medicare. In addition, the PMPM should cover the additional technology required for reporting to the payer.
Two Forum experts answered this question together: Dawn Boyd, director, managed care contracting, The Godbey Group, Irving, Texas, and Dan McAffee, senior managing director, payor contracting and reimbursement strategy, The Godbey Group.