How much do GPs get paid from insurance companies for having you on file?

How much do GPs get paid from insurance companies for having you on file?
How much do GPs get paid from insurance companies for having you on file?

Author: © koszivu – Fotolia.com

General practitioners as well as doctors for children and adolescents receive so-called capitation payments for their patients who are in their file. Even if you haven’t visited them for a whole year.

The capitation payment is determined by the reimbursement decree of the Ministry of Health No. 396/2021 Coll., which is valid for the year 2022. However, these payments already cover some procedures that doctors cannot report separately. These include targeted and control examinations, injections, dressings of minor wounds, removal of a foreign body from the nose or ear canal, consultations with patients’ relatives, and the like.

Capitation payments are paid at three different levels, which are differentiated according to several conditions and the extent of the doctor’s office hours.

Basic capitation rate CZK 54 per month per registered insured for general practitioners:

  • the doctor provides services in the range of at least 25 hours per week, which are spread over 5 working days,
  • at least 1 day a week, the doctor prescribes until at least 6 p.m.

Capitation rate in the amount CZK 60 per month per registered insured for general practitioners and paediatricians:

  • the doctor must provide services in his office for at least 30 hours per week, which are spread over 5 working days,
  • at least 1 day a week, the doctor must have office hours until at least 6 p.m.,
  • his patients can make an appointment at least 2 days a week for a fixed hour.

General practitioners who do not meet these criteria have capitation payments only in the amount 51 CZK per month and pediatricians receive CZK 54 monthly.

The patient’s age also has an influence on the capitation payment.

The capitation rate mentioned above is multiplied by the age coefficient, the so-called index, which takes into account the difficulty of patient care in individual age groups. The index is divided into five-year intervals. This index expresses the ratio of the costs of insured persons in a given age group to the costs of insured persons in the age group of 15 to 19 years, clarifies the spokesperson of the General Health Insurance Company (VZP) Victoria Plívová.

The highest index is determined in children aged 0-4 years (4.10) and in patients over 85 years of age (3.40). For example, for a registered insured person who is a child up to the age of 5, the capitation payment is set at CZK 60 (or CZK 54) x 4.10. In contrast, the index for a child aged 5-9 years is 1.90. For insured persons in the 20-24 age group, the index is set at 0.90, and for 25-29-year-olds it is 0.95. And further, in adult patients, the level of the index increases with increasing age, adds the spokesperson.

In addition to capitation payments, physicians are also compensated with a performance-based payment that includes services performed. These can be, for example, preventive examinations, vaccinations, rapid diagnostics, care for diabetics and others. Performances are evaluated with a point value, which is determined by the aforementioned reimbursement decree of the Ministry of Health.

The article is in Czech

Tags: GPs paid insurance companies file

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