The following is an old DPC Agreement we used in 2015. Notice the capitated rate. A large South Texas primary care clinic was the first to approve this direct to employer Agreement at the capitated rate shown which their business manager deemed “fair and reasonable.”
Primary Care Services Agreement
This AGREEMENT is entered into and effective January 1, 2019 by and between (PLAN SPONSO) (hereinafter “Plan”) and (PROVIDER) (hereinafter “Clinic”):
WHEREAS, Plan desires to conduct a Primary Care Plan program whereby certain contractually participating medical providers will be paid a monthly global capitated amount to provide specified Primary Health Care Services to enrolled Plan members who voluntarily enter the Program; and
WHEREAS, Clinic wishes to participate in the Program and to provide said specified Health Care Services to participating Plan members on a capitated basis.
Now THEREFORE, Plan and Clinic agree as follows:
1. CAPITATION
Clinic shall be paid a monthly Capitation Amount for each Plan member properly enrolled in the Program at the Clinic. Payment for each respective member will begin in the month following initial enrollment in the Program. Services will be provided to members through the program for any month or part of any month for which capitation fees are paid for that member.
a. The Capitation Amounts to be paid are as set forth in Exhibit 1, hereto.
b. The count for the number of Plan members upon which the Capitation Amount is paid each month will be determined by Plan and provided to Clinic via an Excel Spreadsheet or standard file transfers. Plan or its designated third party administrator (hereafter “TPA”) will process capitation payments on or about the second Thursday of each month.
c. Capitations are due the month following the service month so that capitations will not be advance payments but, payments for services previously rendered, i.e., capitations for the month of May will be paid on the second claim run in the month of June.
d. Hold Harmless – For the provision of specified Primary Health Care Services to members participating in the Program, Clinic will accept as exclusive payment, the payments called for in this Agreement and Clinic will hold harmless any member enrolled in the Program from payment of any additional amount for specified Primary Health Care Services received at the Clinic except for a $10 office visit co-pay.
2. HEALTH CARE SERVICES
a. Clinic shall provide without limitation all specified Health Care Services to Plan members who are properly enrolled in the Program. The Clinic is responsible for notifying Plan or its designated TPA and their enrolled members in writing of any changes to specified services which includes changes to doctors and covered specialties if applicable.
b. All specified Health Care Services provided by the Clinic’s Family Medicine providers will be covered under the capitation amount. Clinic will receive the same agreed upon Capitation Amount per month per Plan member that is enrolled in the program.
c. Clinic agrees to serve Plan members without age limitation.
d. Clinic agrees to be available, on call, to Plan members twenty-four (24) hours a day, seven days a week.
e. Clinic agrees to provide same day service for Plan member minor emergencies except in extraordinary circumstances, in which case Clinic will see the member the following day.
f. It is understood Plan members participating in the Program should receive their Primary Health Care at the Clinic, except for Emergency Situations and Out-of-State Travel Situations.
3. CARE COORDINATION
a. Clinic shall coordinate the medical care of Plan members participating in the Program.
b. Clinic shall encourage Plan members participating in the Program to seek necessary referrals to other provider and/or specialist providers through the Clinic and Clinic shall keep appropriate records of such referrals.
c. Although Clinic will receive only the agreed upon Capitation Amounts with respect to Plan Members participating in the Program for services identified by CPT code as a “Specified Service”, Clinic will prepare and submit properly coded “claims” to Plan or it’s designated TPA for all Basic Health Care Services provided to enrolled members to facilitate record keeping and care coordination. Such claims will be paid by the Plan at a zero amount for all for “Specified Services” claims billed for the Clinic’s FEIN number. Other services provided by the clinic’s Family Medicine providers that are not identified as “Specified Services” CPT codes will be paid by the Plan as they would be to any other provider filing a properly coded claim.
4. INDEMNIFICATION
Both parties hereby agree to indemnify and hold harmless the other party and its directors, officers and employees against any and all loss, liability, damages, penalties and expenses, including attorneys’ fees or other cost or obligation resulting from or arising out of claims, lawsuits, demands, settlements or judgements resulting from or arising out of any acts or omissions of either party or its directors, officers or employees which have been adjudged to be grossly negligent, dishonest, fraudulent or criminal or in material breach of the terms of this Agreement.
5. AMENDMENT OR MODIFICATION
This Agreement may be amended or modified only by written agreement signed by both parties hereto. Such amendments or modifications will be effective no sooner than 90 days from date of written agreement to amend or modify this Agreement.
6. REPRESENTATIONS, WARRANTIES AND COVENANTS
Each of the parties hereto warrants and represents that it has the authority, corporate and otherwise, to enter into this Agreement and perform in accordance with the terms hereof.
7. TERM OF AGREEMENT
Subject to the terms of this section, this Agreement shall have a term of one (1) year starting as of the date first written above with the option to renew for four additional one year periods. Either party may terminate this Agreement at its sole discretion, with or without cause, by sending a written notice of termination to the other party. Such notice shall specify the termination date, which shall be no sooner than ninety (90) days from receipt of notice.
8. NOTICES
Any notice required or permitted to be given pursuant to this Agreement shall be in writing and shall be either hand-delivered or deposited in the United States mail, by registered or certified mail, return receipt requested, addressed as follows:
Notice shall be effective upon receipt. Either party may change the address to which notices are to be delivered by giving written notice to the other party as provided in this section.
IN WITNESS WHEREOF, this Agreement has been duly executed by the parties hereto as of the date first written above.
(PLAN SPONSOR)
By:_______________________________________ __________________________________
Name Signature
Title:_____________________________________
(PROVIDER)
By: _______________________________________ __________________________________
Name Signature
Title:_______________________________________
Exhibit 1
Capitation Rate
☐ (PROVIDER) may develop capitation rate based upon actuarially adjusted services historically rendered by the provider and the PMPM clinic cost for those services, plus a margin. If this method is selected, the capitation rate shall be $_______ per member per month.
☑ In the alternative, the capitation rate shall be $ 17.28 per member per month.
Exhibit 2
PRIMARY CARE “SPECIFIED SERVICES”
In consideration for the monthly capitation rates set forth in Exhibit 1, Services for following CPT codes are identified as the “Specified Services” subject to the global capitated payment for services provided by Primary Care Providers of (PROVIDER):
| Office Visits | |
| 99211 | Nursing |
| 99212 | Established Brief Visit |
| 99213 | Established Office Visit Brief |
| 99213 | Established Office Visit Limited |
| 99214 | Established Office Visit Extended |
| 99215 | Established Office Visit Comprehensive |
| 99201 | New Patient Brief |
| 99202 | New Patient Limited |
| 99203 | New Patient Intermediate |
| 99204 | New Patient Extended |
| 99205 | New Patient Comprehensive |
| 99242 | Pre-op Physical expanded |
| 99243 | Pre-op Physical Detail |
| 99244 | Pre-op Physical Comprehensive |
| 99381 | New Patient Physical under 1 yr. |
| 99382 | New Patient Physical age 1-4 |
| 99383 | New Patient Physical age 5-11 |
| 99384 | New Patient Physical age 12-17 |
| 99385 | New Patient Physical age 18-39 |
| 99386 | New Patient Physical age 40-64 |
| 99387 | New Patient Physical age 65 and older |
| 99391 | Established Patient Physical under 1 yr. |
| 99392 | Established Patient Physical age 1-4 |
| 99393 | Established Patient Physical age 5-11 |
| 99394 | Established Patient Physical age 12-17 |
| 99395 | Established Patient Physical age 18-39 |
| 99396 | Established Patient Physical age 40-64 |
| 99397 | Established Patient Physical age 65 and older |
| G0101 | Pelvic & Breast Exam |
| 90050,S | Sports Physical |
| 90050,C | Camp Physical |
| Abscess and Cyst Drainage or Aspiration | |
| 10060 | Incision and Drainage Abscess Simple |
| 10061 | Incision and Drainage Complicated or Multiple |
| 10080 | Incision and Drainage Pilonidal Cyst |
| 10160 | Puncture aspiration of abscess or hematoma |
| Skin Tag Removal | |
| 11200 | Skin Tag Removal up to 15 |
| 11201 | More than 15 Additional cost |
| Excision Of Lesions | |
| 11400 | Excision Benign Lesion Trunk, Arms, Legs (0.5cm or less) |
| 11401 | Excision Benign Lesion Trunk, Arms, Legs (0.6 cm up to 1.0 cm) |
| 11402 | Excision Benign Lesion Trunk, Arms, Legs (1.1 cm up to 2.0 cm) |
| 11403 | Excision Benign Lesion Trunk, Arms, Legs (2.1 cm up to 3.0 cm) |
| 11420 | Excision Benign Lesion Scalp, Neck, Hands, Feet (0.5 cm or less) |
| 11421 | Excision Benign Lesion Scalp, Neck, Hands, Feet (0.6 cm up to 1.0 cm) |
| 11422 | Excision Benign Lesion Scalp, Neck, Hands, Feet (1.1 cm up to 2.0 cm) |
| 11423 | Excision Benign Lesion Scalp, Neck, Hands, Feet (2.1 cm up to 3.0 cm) |
| 11440 | Excision Benign Lesion Face, Ears, Eyelids, Nose (0.5cm or less) |
| 11441 | Excision Benign Lesion Face, Ears, Eyelids, Nose (0.6 cm up to 1.0 cm) |
| 11442 | Excision Benign Lesion Face, Ears, Eyelids, Nose (1.1 cm up to 2.0 cm) |
| 11443 | Excision Benign Lesion Face, Ears, Eyelids, Nose (2.1 cm up to 3.0 cm) |
| Cryosurgery Skin Lesion | |
| 17000 | Destruction skin Lesion one only (Ex. cryosurgery) |
| 17003 | Destruction skin Lesions 2-14 Additional Cost |
| Nail Procedures | |
| 11719 | Trimming nails |
| 11765 | Ingrown Toe Nail Removal |
| 11730 | Nail Avulsion |
| 11740 | Subungual Hematoma Evacuation |
| Wart Destruction | |
| 17110 | Wart Destruction up to 14 (Cryosurgery) |
| Simple Suture Repairs | |
| 12001 | Suture Wound Scalp, Neck, Trunk, Hands, Feet(2.5 cm or less) |
| 12002 | Suture Wound Scalp, Neck, Trunk, Hands, Feet(2.6 cm to 7.5 cm) |
| 12004 | Suture Wound Scalp, Neck, Trunk, Hands, Feet(7.6cm to 12.5 cm) |
| 12011 | Suture Wound Face, Ear, Nose, Lips (2.5cm or less) |
| 12013 | Suture Wound Face, Ear, Nose, Lips (2.6 cm to 5.0 cm) |
| 12014 | Suture Wound Face, Ear, Nose, Lips (5.1 cm to 7.5 cm) |
| Splint Applications | |
| 29125 | Short arm splint |
| 29105 | Long arm splint |
| 29505 | long leg splint |
| 29515 | short leg splint |
| 29130 | Finger Splint |
| Misc. Procedures | |
| 69209 | Ear Wash |
| 94640 | Nebulizer Treatment |
| 92552 | Hearing Test (Audiometry) |
