General Questions

The agreement is appended as Schedule R of the Memorandum of Agreement (MOA) and is available in its entirety here. The latest version is dated October 11, 2023.

Recent Amendments to Schedule R of the MOA can be found by clicking here.

Family physicians, who are interested in participating in the Blended Capitation program, must submit an expression of interest form. Please note the form is an expression of interest only and represents an ongoing process—there is no deadline for submission.

To submit your expression of interest, please click here.

  • The acceptance date into the Blended Capitation Program is the date the signed Letter Agreement and initialed Appendices A and B for each physician in your group are received by FPRP. When Blended Capitation Groups (BCGs) are issued letter agreements for review and execution, they have six months for at least three physicians within group to submit their signed letter agreements and initialed appendices to FPRP. After six months the letter agreements will be void.
  • All of the initial members of your group will have the same acceptance date. Please note that your acceptance date may not be the date that you signed your individual physician’s letter agreement. To request confirmation of your acceptance date, contact the Blended Capitation Program Manager, Melissa Sullivan at msullivan@nlma.nl.ca.
  • Grants and stipends will be authorized for payment once all physicians within a BCG submit their signed letter agreements and appendices.

Participation in the Blended Capitation Model (BCM) is voluntary. Physicians enrolled in the model may voluntarily choose to go back to fee-for-service. Physicians may discontinue their enrolment by submitting a Blended Capitation Withdrawal Form at least 30 days before their desired end date. Upon discontinuance from BCM, the physician shall notify attached patients that the physician will no longer be providing services under the Model.

Once a physician withdraws from BCM their patients will be de-rostered from the BCM billing system and the physician will return to billing 100% FFS. If they wish to rejoin the BCM they will need to re-apply by submitting a new Expression of Interest Form.

As per Section 9 of the BCM Policy Guide, if a physician’s departure reduces their Blended Capitation Group (BCG) to fewer than three physicians, the BCG is expected to make a diligent effort to find a new physician to join the group as quickly as possible. FPRP will monitor the group’s efforts every 12 months and will assist the BCG to identify and connect with other potential group members.

Once a Blended Capitation Withdrawal Form is received by the Family Practice Renewal Program (FPRP), the withdrawing physician will be contacted within 30 days with instructions concerning the return of any owing amounts for pro-rated grants and stipends.

  • One-Time Start-Up Grant ($10,000) – pro-rated
  • Annual Quality of Care Stipend ($7,500) – pro-rated
  • Transition Incentive ($11,250) – not pro-rated
  • EMR Transition Grant ($30,000) – not pro-rated

Returning Overpaid One-Time Start-Up Grant and Annual Quality of Care Stipend

The One-Time Start-Up Grant ($10,000) and Annual Quality of Care Stipend ($7,500) are based on one-year participation in the BCM, starting with the acceptance date (i.e., the date upon which the physician’s signed Letter Agreement and initialed Appendices A and B are received by FPRP), and will be pro-rated in the event of a physician’s departure from the Model. Overpaid funds will be recovered from the physician.

Overpayment recoveries will be coordinated by the FPRP and the departing physician will be invoiced for any overpayment with full payment due in 30 days.

The formula for calculating the amount of funds to return is as follows:

  • (Full fund amount / 365) x days enrolled in BCM = amount physician retains
  • Full fund amount – amount physician retains = amount physician returns
Example:

Physician enrolled for 90 days and decides to withdraw and return overpaid portion of $10,000 One-Time Start-Up Grant.

($10,000/365 days) x 90 days = $2,465.75

$10,000 – $2,465.75 = $7,534.25

Transition Incentive

The Transition Incentive ($11,250) is not pro-rated. Providing a physician has made a full transition to the BCM, no funds will be recovered. However, if a physician withdraws from the Model and later wishes to rejoin, a second Transition Incentive will not be paid.

EMR Transition Grant

The EMR Transition Grant ($30,000) is not pro-rated. Providing a practice has fully transitioned to the Provincial EMR, or is committed to completing the transition process, no funds will be recovered. However, if a practice leaves the Model and later wishes to rejoin, a second EMR Transition Grant will not be available.

Full transition to the Blended Capitation Model

Full transition to the BCM represents 18 months in the model (starting with the physician’s date of acceptance).

The BCM Sub-Committee is established by the Family Practice Renewal Committee (FPRC) to make recommendations to FPRC, and to make decisions on behalf of FPRC (within delegated authorities, as set out in this Terms of Reference) relating to key design features of the BCM program, whose mandate is established within Schedule R, a Blended Capitation Agreement for Primary Care.

In fulfilling its role, the BCM Sub-Committee will consider relevant experience from other Canadian jurisdictions, and how these lessons apply to family practice realities in Newfoundland and Labrador. Sub-Committee members will be expected to coordinate, inform & assess Sub-Committee proposals with their respective organizations before presentation to FPRC for final decision.

MEMBERS

  • Dr. Lynette Powell, Family Physician, GFW, NLMA (FPRC Co-Chair)
  • Dr. Paul Coolican, Family Physician, St. John’s, NLMA
  • Dave Moore, Director Medical Services, DHCS (FPRC)
  • Matthew Pinsent, Sr. Manager, Medical Services, DHCS

EX-OFFICIO

  • Chad Perrin, Program Director, FPRP
  • Melissa Sullivan, Program Manager, Blended Capitation, FPRP
  • Dana Howse, Program Specialist, Blended Capitation, FPRP
  • Jason Clarke, Program Specialist, Blended Capitation, FPRP
  • Rana Fudge, Manager of Digital Health, DHCS
  • Enaam El-Amassi, Manager of Financial Analysis, DHCS
  • Glenda Nash, Associate Executive Director, NLMA
  • Scott Brown, Director, Health Policy & Economics, NLMA
  • Aimee Letto, Health Policy Analyst & Legal Counsel, NLMA

MUN student health physicians could be eligible to participate in the Blended Capitation Model (BCM). Students/families would only be rostered for their period at MUN, but during that time they would receive comprehensive, longitudinal care from their physician and the group. As long as those patients are not rostered to another physician in their home community, this is fine. There might be some unique considerations given the nature of the practice (for example, perhaps around de-rostering patients as they graduate or otherwise leave the university), but we do not think those would prevent you from participating in the BCM. Please note that as a BCM physician you will be subject to the $56,000 cap for non-rostered patients.

 

Participation in the EMR program does not come with cyber security insurance or advice. CMPA will cover the cost of notifying patients of a breach but no other costs related to a privacy or security breach.  The NLMA recommends physicians get cyber security insurance through their own insurers.  The Association also recommends physicians, and their staff, complete the cyber security training, eCE Shield offered by eHealth Centre of Excellence. https://ehealthce.ca/Shield.htm.

Timelines

Physicians who have already completed an expression of interest and subsequently submitted their practice profile to the FPRP will receive an update on their eligibility status from FPRP. Once eligibility is confirmed, the FPRP will send out an email to each eligible physician to confirm the income floor.

Your agreement to the income floor calculation will be required prior to issuance of an agreement for enrollment in the new payment model. Physicians who have met the eligibility requirements and have confirmed their income floor calculation will receive a letter of agreement from FPRP for enrollment in the Blended Capitation Program.

Please see the Path to Acceptance for further information.

Starting October 30, 2023, doctors will be accepted into the program, which means they will have access to the one-time bonuses and the income guarantee. The billing system for capitation claims and partial fee-for-service claims will be ready no later than April 1, 2024.

On April 1, 2024 the first BCM Group will begin the onboarding process to the BCM billing system. The billing system will be implemented one BCG at a time, with support from eDOCSNL and the Blended Capitation Program. A BCG will only begin billing in the new BCM system after it has been onboarded with eDOCSNL support, which will include demos and training. Physicians will continue to bill 100% FFS after April 1, 2024 until they meet with eDOCSNL to be onboarded to the BCM billing system.

Once the reliability and accuracy of the billing system are confirmed, on or before July 1, 2024, the billing system will be open to all other applicants who have been accepted into the program. In the coming months and years, the NLMA will monitor the program to determine if changes need to be negotiated in the MOA.

A summary of each step in the Path to Acceptance can be found here. It is important that all physicians interested in the Blended Capitation Program familiarize themselves with the Path to Acceptance.

Billing System

On April 1, 2024 the first Blended Capitation Group will be onboarded to the BCM billing system. The billing system will be implemented one BCG at a time, with support from eDOCSNL and the Blended Capitation Program. A BCG will only begin billing in the new BCM system after it has been onboarded with eDOCSNL support, which will include demos and training. Physicians will continue to bill 100% FFS after April 1, 2024 until they meet with eDOCSNL to be onboarded to the BCM billing system.

MCP will send a message notifying you that your patient has been de-rostered from their system, which will stop the capitation payment associated with that individual, but the “Blended Capitation” box will remain checked in your EMR billing window. For patients who will be permanently de-rostered, you will need to uncheck the “Blended Capitation” box to ensure patients’ roster status is accurate on your end, so that you are billing appropriately.

Forming a Blended Capitation Group

You can have success with any size group. The size of the BCG impacts many aspects of a practice: physician schedules related to regular, reasonable hours; how competing demands outside of the practice are managed; distribution of after hours responsibilities to name a few considerations. Other provinces have demonstrated success with BCGs of varying sizes.

A group of physicians in the Blended Capitation Model do not need to co-locate in the same physical space. After-hours care for patients within the group can be provided virtually and in-person.

FPRP has a Practice Facilitator who can assist you in finding other physicians who are interested in forming a Blended Capitation Group.

Co-location is not a requirement; groups do not have to be under the same roof.

A Group must consist of at least 3 physicians. Consistent with Schedule R, when a Group falls below 3 Physicians, the goal of the Group and the FPRC is to re-establish the minimum number of Physicians in a reasonable period. It is expected that the Group will make diligent efforts to recruit a new physician(s) to the Group as quickly as possible. The FPRC will review the Group’s efforts every 12 months to determine if a reasonable effort has been made. The FPRC’s determination will take into account the general conditions for recruitment of Physicians within the region and the province as a whole.

The FPRC will not terminate a Group if the Group is making reasonable efforts to recruit the minimum number of Physicians. The FPRC will support the process by promoting the opportunities of the Blended Capitation Model to other physicians and identifying opportunities for Group mergers. The final decision on the physicians who will be part of a Blended Capitation Group – whether through recruitment or a merger with another Group – will be that of the Group Physicians.

During the period of time in which the Group continues to practice with fewer than 3 Physicians, the Group, in consultation with the FPRC, is to continue to provide services to all attached patients of the remaining Physicians as per Schedule R of the MOA; consistent with the foregoing, the FPRC will consider, at the request of the Group, a proportionate reduction in the after-hours service of the Group for this time and any extension of time as approved by the FPRC, but in any event, the remaining Physicians are to provide a minimum of 3 hours of after-hours clinics per week.

In the event a termination of a Group occurs, the Physicians will transition back to Fee for Service (FFS) in accordance with Schedule R.

The FPRC may update its rules and processes regarding transitions in Group composition from time to time.

See more about group composition in the BCM Policy Guide, Section 9.

No. Members can apply to enroll in the Blended Capitation Program prior to making arrangements with a group. FPRP provides matching support to physicians seeking other group members. 

Family physicians who are interested in participating in the Blended Capitation program must submit an expression of interest. To submit your expression of interest, please click here. 

Continuing with multiple EMR instances in a BCG will introduce additional considerations that will require some decision-making in consultation with eDOCsNL. Moving all members of the BCG to a single EMR instance will facilitate information sharing, patient care coverage and appointment booking across physicians and practice locations in the BCG. However, combining instances will introduce a delay to onboarding to BCM in order to migrate patient data to a single instance. Please reference this graphic outlining the pros and cons of combing two or more EMR instances as you consider your best option. 

Please see: Considerations for joining a common instance or maintaining separate EMRs Blended Capitation Groups in Multiple EMR Instances. 

Incentives, Grants, and Stipends

Grants and stipends will be released following FPRP’s receipt of the signed Letter Agreement and initialed Appendices A and B from each physician within a blended capitation group. We are aiming for a 30 day process time.

Grants and stipends will be authorized for payment once all physicians within a BCG submit their signed letter agreements and appendices.

On the acceptance date of a newly-established Group, each member of the Group will be entitled to receive:

1. A $11, 250 Transition Grant from Government; and
2. A Start-Up Grant of $10,000 from the FPRC.

On the acceptance date of an individual physician who is joining an established Group, the physician will be entitled to receive from the Government a transition grant of $11,250. The $10,000 Start-Up Grant is not available to physicians joining an established Group.

Each physician on their acceptance date will be entitled to receive from the FPRP an annual quality of care stipend of $7,500 in recognition of the physician’s participation in FPRP or practice-initiated quality programs, practice improvement and related professional development. Entitlement to the payment of this stipend will at all times be subject to the application of FPRP guidelines with respect to the professional development initiatives that will be considered as acceptable for purposes of the stipend. Please see Section 14 of the BCM Policy Guide for a list of qualifying activities. Grants and stipends will be pro-rated in the event of a Physician’s departure from the Model, as follows:

• One-Time Start-Up Grant ($10,000) – pro-rated
• Annual Quality of Care Stipend ($7,500) – pro-rated
• Transition Incentive ($11,250) – not pro-rated
• EMR Transition Grant ($30,000) – not pro-rated

Please see the Discontinuance Policy (Section 20) in the BCM Policy Guide, for details concerning the calculation and repayment of pro-rated grant and stipend funds.

Procedures Bonus

Each physician will be entitled to receive an annual procedures bonus as follows:

1. A Physician will be entitled to the bonus who bills $1,200 of in-basket Procedures fee codes (as set out in Appendix B to Schedule R of the MOA) in a calendar year, with the $1,200 measured according to 100% of MCP Medical Payment Schedule;
2. Bonus payment of $2,500;
3. Procedures bonus is payable when the above billing threshold is achieved during the year.

For the Procedures Bonus, a “calendar year” is every twelve-month period starting with the acceptance date. For physicians who join an established BCG, who have a different acceptance date from the original group, the bonus will be pro-rated in the first year according to the number of days the physicians are in the model. For example, if the group’s original acceptance date is April 1, 2024, and a physician joins the group on October 15, 2024, then the new physician would be eligible to receive a Procedures bonus on April 1, 2025, in the amount of:

$2,500/365 = $6.85 per day
Apr 1 to Oct 15 = 197 days
197 days x $6.85 = $1,349.32

 

Yes

Learners

If a learner sees one of your rostered patients on your behalf, the service will be billed at 100% fee for service (FFS). ​

These billings by learners will not affect the FFS cap of $56k, which is only applicable to in-basket services provided to non-rostered patients

For the purposes of billing under the BCM, a learner is any medical learner who is training to be a family physician. This includes first year placement students. It does not include nurse practitioners or Practice Ready Assessment candidates.

Locums

Locums will be paid by the blended capitation group.  Capitation revenue will come to the group regularly over 26 pay periods, and this revenue is the main source of funding to pay locums when they are replacing a physician.  The locum’s services will also be billed to MCP, and this serves as an additional source of funding to pay the locum.  If a group chooses not to use a locum during a physician’s leave, the capitation funding will remain within the practice.

Locum arrangements may vary based on terms decided upon by the host physician and locum.

No recommendation has been developed on a locum rate. ​

Locum physicians will submit all billings for services rendered through the locum physician’s billing number, with the payment assigned to the blended capitation physician or blended capitation group. This will generate the FFS payment for in-basket services delivered to attached patients, as well as the FFS payment for out-of-basket services delivered to all patients and in-basket services delivered to non-attached patients.  ​

The typical payment agreement often includes an hourly rate paid to the locum, and FFS could be kept by the host physician or paid to the locum. There are different ways those two elements can be balanced to produce a fair and appropriate arrangement.  A sample contract template for locums will be developed by FPRP.

If a group chooses not to use a locum during a physician’s leave, the capitation funding will remain within the practice.

See also the BCM Policy Guide, Section 8, Locums.

Yes, FPRP now offers additional follow-up appointments with a consultant (Barbara Molgaard Blake), during which she can work with individual physicians to prepare a cash flow analysis for your practice, as well as map out potential locum payment scenarios. Click this LINK to schedule a meeting.

 

There is no maximum amount of time per se. However, per Schedule R, Section 3.5 (d) states, “where reasonably possible, services will be provided by the physicians in a Group rather than by locums or subcontractors.”

The Capitation Rate accounts for the cost of a physician hiring a locum for two weeks of practice coverage annually. Physician leave and locum coverage is to be managed by each BCG, and locum payment is to be paid by the physician for whom the locum is providing coverage.

Patients with appointments while a locum is covering care may still be enrolled and rostered with the Blended Capitation physician in the same fashion as if the Blended Capitation physician is present and providing care.

Each physician accepted into the Blended Capitation Program who will utilize locums needs to send an email to Provider Registration (ProviderRegistration@gov.nl.ca) requesting a New Payee # for their own individual practice (i.e., their own payee number, not a single one for the Group). Once the physician gets the new payee number it will be used on their locum’s provider card.  Please note that a physician only needs to request this number once and then it will be used going forward for locum coverage.

The FPRP launched an advisory service to support physicians who wish to map out potential locum payment scenarios for your practice.  While rates may be part of this discussion, the BCM rollout will not include a set provincial locum rate.

Appointment availability is generally available every Tuesday and Thursday evening from 7:00 p.m. – 9:00 p.m. NT. Please visit the booking website to look at available appointment times and book a meeting.

The FPRP has also developed a Locum Agreement Template as a tool to support Blended Capitation Groups to plan for locum coverage. This will be finalized and made available as an online resource soon.

All physicians will bill 100% FFS for non-rostered patients. After a patient is rostered, the billing system will automatically convert the fee to the appropriate amount for in-basket (25%) or out-of-basket (100%) services, regardless if the primary physician or locum is providing the service. The locum will be paid by the Blended Capitation physician who is being covered by that locum.

Please also see Q 10 under Rostering: Should we wait until our entire panel is enrolled before we roster them in the billing system?

Both payments will come in a single payment. The two separate amounts will be delineated in the pay stub.

Payment and Income Floor

Yes, the FPRP launched an advisory service to support physicians who wish to explore what moving to the Blended Capitation Model means for their individual practices.

Services consist of a consultant (Barbara Molgaard Blake) with whom you can book an initial meeting to explore how you can use your EMR data to define your panel of patients, predict your future income and answer any questions you may have on the Model. This information can help inform your decision on whether to move to Blended Capitation.

FPRP also offers additional follow-up appointments with Barbara, during which she can work with individual physicians to prepare a cash flow analysis for your practice, as well as map out potential locum payment scenarios. It is recommended that the BCM 60-min meeting (follow-up) session is selected if looking for assistance with cash flow analysis.

Please visit the booking website to look at available appointment times and make a booking.

As of the commencement date of the billing system and, subject to the provisions of the test group, each physician will receive from MCP:

  1. a base capitation payment for each attached patient, adjusted for each patient by the complexity modifier table attached to Schedule R;
  2. FFS payments at 25% of the rate in the MCP Payment Schedule for in-basket services provided to attached patients; and
  3. FFS payments at 100% of the rate in the MCP Payment Schedule for all other services, including services provided to patients not on the Roster of the Group.

On October 11, 2023, the base capitation rate was amended to be $186.29 per attached patient. The base capitation rate, and the complexity modifier, may be adjusted from time to time as mutually agreed in writing by the Government and the NLMA. Schedule R – Appendix A has been amended to reflect the updated base Capitation Rate.

Following the end of a physician’s two-year Income Floor period, the annual FFS billings of a physician for in-basket services provided to patients who are not attached patients is capped at $56,000. For greater certainty, there is no limit to FFS billings of a physician for out-of-basket “services” to rostered and non-rostered patients.

Please refer to section 3.7 of Schedule R for a full description of the payment blend.

  1. Up until a patient is rostered in the billing system (eDOCSNL will provide related training during your BCG’s onboarding process to the billing system), you and/or your office staff would submit billing as per the regular process (FFS – 100% MCP billing).
  2. Once a patient is rostered, and a billing submission is made, go-forward payments payment will consist of a:
    • Capitation payment, which is broken down and paid bi-weekly (by patient- $186.29 times Complexity Modifier divided by 26), and
    • A fee-for-service component, which is 25% of the MCP billing for that office visit for in-basket codes as calculated by the billing system.  (Out of basket codes will continue to be calculated at 100% by the billing system.)
  3. Your patient roster continues to build as each patient is attached as an ongoing process, and the capitation payment will be adjusted as patients are rostered and de-rostered in the system.

Over time, as a physician rosters more and more patients, the ratio of capitation payments to FFS payments will increase. And, the two-year income floor period provides the support of a minimum guaranteed income during this transitional period.

Please also refer to Question #10 in this section relating to cash flow, and Question #1 under Rostering for more information about patient enrollment and rostering.

The Income Floor is established by Schedule R of the Memorandum of Agreement. Physicians who choose to enroll in the new payment model will receive a guaranteed income floor in the first two years to facilitate the transition. The Income Floor is calculated by averaging two recent, representative years of active practice in Newfoundland and Labrador, plus a 10.9% premium payment applied in Year One.

The Blended Capitation Income Calculation spreadsheet identifies your proposed Income Floor for Year One in the Blended Capitation Program and contains a listing of up to the last five fiscal (April 1 to March 31) years of your bi-weekly FFS billings. This data is provided by MCP for the purpose of calculating your Income Floor. It excludes: sessional fees, on-call fees, other compensation for services provided within a health authority or out of province patient claims. It is presumed that physicians will continue to provide such services into the future, and therefore would not be part of the guarantee.

Physicians who have already completed an expression of interest and subsequently submitted their practice profile to the FPRP can expect an update on their eligibility status in the next several weeks.

Once eligibility is confirmed, FPRP will send out an email on behalf of the FPRP to each eligible physician to confirm the income floor with applicants and the Department of Health and Community Services prior to issuing letters of agreement for enrollment in the new payment model.

The email sent by FPRP will contain a link to an Income Floor Decision Form; please use the form to indicate your response to your calculation. You may choose to accept the calculation or request a review of your Income Floor.

If you indicate on the Income Decision Form that you would like a review of your Income Floor, you will be contacted by the Blended Capitation Advisor to book a session to review your request and to prepare any relevant documentation for submission for reconsideration.  A session with the Blended Capitation Advisor is mandatory prior to having any review of your Income Floor completed.

Your agreement to the income floor calculation will be required prior to issuance of an agreement for enrollment in the new payment model (Step 6).

The start date for accepting family physicians into the model is October 30, 2023.

The Income Floor for physicians without a two-year billing history and physicians who do not have an established patient panel, will be at Step 1 from the MOA, or for a physician transitioning from a salaried position, their current Step of the Salary Scale for family physicians.  The total amount will be adjusted to the proportion of FTE of comprehensive primary care the physician commits to provide in accordance with the table below.  An additional 30% will be added to this amount in recognition of overhead expenses, and an additional 10.9% payable in year one of the Income Floor period.

The amount of FTE of comprehensive primary care that will be required to qualify for payment under Article 3.12(b) of Schedule R will be determined according to the number of three-hour community medicine blocks provided per four-week period.

Please click the image below for income floor calculations.

Income floors aren’t recalculated during the income floor period.

This is a term of Schedule R and Article 10 (1) of the Medical Care and Hospital Insurance Act which stipulates that “A participating practitioner shall submit an account for an insured service no later than 90 days after the practitioner provides the insured service” (i.e. physicians must submit billings to MCP within 90 days of the date of service).

If physicians have not signed their letter agreement, this is reasonable. However, unless their practice pattern has changed in a material way this may be an unnecessary step. Fiscal year billing data for 2023-24 will be available after the final pay period of 2023-24 (i.e. pay period 26 is paid March 22, 2024).

Commencing on the acceptance date into the Model (the date when signed letter agreements and initialed appendices for each physician in a group are received by FPRP), each member of the Group will for a period of two years be entitled to receive a guaranteed minimum level of compensation provided to physicians participating in the Model in accordance with Article 3.12 of Schedule R of the MOA (the “Income Floor”). It will follow the MCP billing schedule (see the BCM Policy Guide Sections 11 and 12).

Per BCM Policy Guide Section 12, if in any one or more of the four six-month periods commencing on and following the acceptance date, a physician’s billings under the Model, including billings for out-of-basket services and for non-rostered patients are less than the Income Floor for such six-month period, the physician will be entitled to receive from the Government a top-up payment equal to the amount by which the Income Floor amount exceeds the Model income. Given MCP Billing rules, physicians will be topped up 90 days after the first six-month period following acceptance, then every 6 months thereafter.

Example:

If a group is accepted into the Model on November 1, 2023, the physicians would continue billing FFS until they are onboarded to the BCM billing system. No matter when they start billing under the BCM, the physicians would be eligible for their first top-up payment as of August 1, 2024 (allowing for assessment of the six-month billing period plus the 90- day window per MCP billing rules). Physicians would be eligible for the second top-up payment at the end of the next 6-month billing period (if their remuneration remains below the income floor) on February 1, 2025, which would already include the 90-day window.  After the first payment, payments would occur every 6 months.

The capitation and top-up payment processes and timelines have been reviewed by the NLMA and the Department of Health and Community Services and both partners are confident physicians should not experience significant cash flow challenges.  Physicians can continue billing 100% FFS for any patients who are not rostered. Physicians can bill 100% FFS for any healthcare provided until the patient is rostered.

To ensure you receive 100% for the patient visit, create and submit the bill same day as the visit.  Do not submit the rostered bill at the time of the visit as it will reduce the bill to 25% if submitted as part of the visit.  The Rostered bill should be submitted on a different day after the visit to ensure there in no impact on the previous bills submitted. Once the patient has been rostered within the EMR then the physician will start receiving 1/26 payments of the cap fee every 2 weeks. Then when the patient comes in again they will bill 25% FFS for that visit.

Physicians would continue to bill 100% FFS, and would be paid as per Schedule R. The 10.9% premium relates only to the income floor. See Schedule R, Section3.12 (c): “If the Model and billing system are not operational when a physician enters year two of the Income Floor period, the income floor will be adjusted by the 10.9% premium on a month-to-month basis until the billing system is ready.”

This will occur as part of regular negotiation cycles between government and the NLMA (i.e. the MOA negotiations). Note the current modifier was recently developed based upon NL data and is a NL specific solution.

You’re correct that the long-term care codes are not in the basket of services and can therefore be billed at 100% with no cap.

The basket of services is listed in Schedule R – Appendix B.

The model is designed around providing care to rostered patients, with the $56,000 FFS cap providing flexibility to see some non-rostered patients.

Per Schedule R, Section 3.9, there is no cap during a physician’s first two years in the model. After the two-year income floor period, any FFS billings for in-basket services provided to non-rostered patients will be capped at $56,000. There will be no remuneration under the BCM for billings exceeding the $56,000 cap. Note there is no limit to FFS billings for out-of-basket services provided to rostered and non-rostered patients.

The one-time start-up grant of $10,000 paid by FPRP to each physician upon acceptance into the Program, and who is part of the blended capitation group at the time of the Group’s establishment, is intended to cover expenses such as those you describe, as well as expenses such as technology, renovations, and professional services.  Schedule R does not provide for any additional compensation.

A new Blended Capitation billing system will extract roster numbers from each physician’s EMR. This data will be collected every 24-48 hours and the biweekly capitation payment will be updated accordingly.

You will still receive capitation payments for rostered patients that you see infrequently, regardless of how many appointments they have. It is important to review your roster to ensure these patients have not moved or are receiving care from a different physician, per Section 3.4 of Schedule R.

Yes, patients will be automatically de-rostered from the Blended Capitation billing system and capitation payments for them will stop if they: roster with another physician, move out of province, are admitted to long-term care, have an expired MCP card, or die. MCP will send physicians an EMR message indicating that a patient has been de-rostered and the reason why.

Per the Service Expectations (Section 3.5 of Schedule R) each physician will coordinate with the other physicians in the Group as required to ensure that non-emergency primary care services will be accessible to meet the health needs of the patient population served.  The model is flexible enough to allow physicians in a group to divide work in the above mentioned manner, upon mutual agreement with their patients and each other, with one physician performing one type of procedure and another performing other procedures.  However, there is no additional compensation under the model.  Physicians in a group may choose to address these types of issues through a group governance agreement.

Yes. If you provide care to patients in LTC you will bill 100% FFS for out-of-basket services to a non-rostered patient, and that would be included in the top-up calculation.

Both payments will come in a single payment from MCP. The two separate amounts will be delineated in the pay stub.

MCP will include a message to notify physicians who are approaching their 56K cap in their billing remittance statement.

No. Per Schedule R, Section 3.9, the 56K cap will be implemented following the two-year Income Floor period. This allows two years for Blended Capitation physicians to bill at 100% FFS for non-rostered patients while they merge their EMRs and roster their patients.

There is no change to the MCP claims monitoring system as a result of Blended Capitation. The MCP portion of a physician’s income will become less financially significant as physicians will receive 25% of the value of MCP billings, which will represent about 20% of their overall income. The 80% of income that is derived from capitation will be freer from administrative burden with a more straightforward billing process.

Please refer to Schedule R Section 3.5 for service expectations of physicians participating in the Blended Capitation Model.

Capitation payments are paid biweekly with the expectation that care is being provided to rostered patients. In the case of physician leave (e.g., vacation, professional development, medical, and parental leave), patient care should be covered by a locum or another member of the Blended Capitation Group (BCG). Blended capitation physicians taking parental leave are eligible for the NLMA Parental Leave Allowance.

Physicians taking leaves longer than 30 consecutive days and who have not arranged for another provider within their group or a locum to cover their patients’ care will have their blended capitation payments paused during the period they are absent, from day 31 of leave until they return. Physicians are to notify FPRP in writing in advance of the dates of the leave period by submitting an Extended Leave Form (form to be available soon on the FPRP website).

Physicians are encouraged to develop a group governance agreement to outline, among other things, how leave will be managed by the group including whether locums or other group members will be engaged to cover patient care, an understanding of what patient care is to be covered, and how capitation and FFS payments for that care will be allocated.

The program acknowledges that there may be occasions when physicians are unable to arrange care coverage for their patients including instances of unplanned leave. In such cases, the physicians should notify FPRP as soon as practicable to discuss their circumstances and to minimize payment impacts. In these instances, please email the Blended Capitation Program Manager, Melissa Sullivan, at msullivan@nlma.nl.ca.

 

Per FAQ question 2 under Rostering and section 7 of the BCM Policy Guide, a patient with an expired MCP card will be automatically de-rostered from the BC billing system and they will not be eligible for billing under BCM or FFS. No retroactive capitation payments will be issued. To avoid interruptions in capitation payments and limit issues with expired MCP cards, office staff are encouraged to check each patient’s MCP card when booking appointments and at check-in to ensure they are valid.

Yes. If a rostered patient travels out of province, for any reason, for any duration, their BCM physician will continue to receive capitation payments.

Performance Indicators

The objective of the performance indicators process is to encourage continuous improvement and/or maintenance of accessibility and high-quality care. Therefore, there are no specific targets or goals attached to these, with the exception of after-hours access.

The approach for defining and measuring access relies on three performance indicators, listed below:

  1. Percentage of same-day or next-day appointments available to attached patients.
  2. After-hours access provided to attached patients. This indicator will be based on the after-hours service expectations, which is driven by a formula.
  3. Relational continuity, meaning the ongoing therapeutic relationship between a family physician, including their team, and an Attached patient. This indicator will measure the proportion of visits by attached patients to their family physician, and to their family physician’s Blended Capitation Group.

The monitoring and evaluation plan is in development and will be communicated to BCGs when finalized.

Practice Facilitation Services

Physicians may benefit from the assistance of a practice facilitator in their BCM journey. The practice facilitator will help practices identify essential BCM processes, optimize operations, improve quality, and ensure success. The practice facilitator can also help address any questions about the BCG process by connecting you with appropriate resources.

The Practice Facilitator (Nancy Dillon) will contact the identified BCG physician lead to coordinate a meeting.

Rostering

There are two steps to adding patients to your Blended Capitation roster:

  1. Patient Enrolment – The Blended Capitation Program has developed a patient enrolment form and information sheet to support the patient enrolment process. It will be available in Med Access after all physicians within your Blended Capitation Group have submitted their signed letter agreements and initialed appendices. With each patient visit, you/your office staff will discuss the enrolment form with patients as part of the check-in process, and the patient’s consent to be enrolled with their physician will be documented in the Med Access form. The enrolment process may also be completed over the phone, with consent recorded in the Med Access form.
  2. Patient Rostering – after your patient has consented to enroll with their physician, they can be rostered in the Blended Capitation billing system by: i. Checking the ‘Blended Capitation’ box, and ii. submitting a Blended Capitation fee code to MCP in the EMR billing window, using the new EMR Blended Capitation functionality. These features will be available to you when your group is onboarded to the BCM. This second step officially rosters the patient and generates capitation payments to the physician.

As part of your BCG onboarding process, the Blended Capitation Practice Facilitator and an EMR Practice Advisor will provide demonstrations, training and support related to patient enrolment and rostering workflows at your clinic. For more detailed information regarding the enrollment and rostering process please view the eDOCSNL Tipsheet.

For guidance related to potential cash flow issues during rostering, please view question #10 in the Payment and Income Floor section above.

 

Due to an MCP system limitation, when a patient’s MCP card expires, they will be automatically de-rostered from the Blended Capitation billing system and they will not be eligible for billing under BCM or FFS. When a patient is de-rostered from the BCM billing system, MCP will send a notification to the physician that their patient was de-rostered via an EMR message.

Once a patient’s MCP card is renewed they can be re-rostered in the BCM billing system by resubmitting the Blended Capitation fee code in the EMR billing window (as done for initial rostering). To limit issues with expired MCPs, office staff are encouraged to check patient’s MCP cards when booking appointments and at check-in to ensure they are valid before care is provided, and if the card is close to expiry to remind them to renew online.

If a patient opts not to roster, the physician can continue seeing them and billing FFS (subject to Section 3.9 of Schedule R, “3.9 FFS Billing for Non-Rostered Patients”). After the two-year Income Floor period, the FFS limit per physician for in-basket services provided to non-rostered patients is $56,000. There is no limit for FFS billings for the provision of “out of basket” services for rostered and non-rostered patients.”

The after-hours requirements relate to rostered patients, but physicians could choose to make after-hours clinics available to other patients (keeping in mind performance indicators).

Over time, the majority of a physician’s patients will likely become rostered. However, some patients may remain outside the roster. This is ok but physicians must fulfill their commitment under Schedule R to providing comprehensive and continuous care to all of their patients: Section 3.3 (a) of Schedule R states that all family physicians will be eligible for payment through the Model, provided they “commit to provide comprehensive continuous primary healthcare services across the life span of their patients, based on patient needs and responsive to documented needs of the geographic community they serve.”

Patient enrolment does not have to occur alongside a patient appointment. Physicians or their office staff may contact their patients by phone to initiate the enrolment conversation, review the Patient Enrolment Information Sheet, and elicit patient consent to enroll, which can be recorded in the electronic Enrolment Form in Med Access. The Patient Enrolment Information Sheet should be emailed to patients where possible. The patient Enrolment Form is located under the task category of Form (Blended Capitation Enrollment) in MedAccess. The information sheet is on page 2; you will need to click on the green arrow to access it.

To identify patients who visit the practice infrequently, EMR reports can be generated to list patients who have not been seen for more than a year and who do not have an upcoming appointment.

Workflows will be discussed during the onboarding sessions with eDOCSNL and FPRP.

Yes. Blended capitation requires a relationship between a patient and a most responsible provider. Under the Blended Capitation Model, two doctors can choose to share that care and see each other’s patients for both after-hours care and for routine medical appointments. However, patients would need to be rostered to one doctor for the purpose of payment.

You can begin enrolling patients as soon as your group is accepted into the Blended Capitation Model (BCM) but rostering (which involves entering a rostering fee code and clicking a “blended capitation” box in the EMR billing window) cannot occur until you are onboarded to the Blended Capitation billing system. You are advised to enroll as many patients as you can now.

No, you don’t need to wait until you’ve enrolled your entire panel to start rostering. Accepted Blended Capitation physicians should start enrolling patients now at whatever speed makes most sense for them given the nature of their practice. However, they are encouraged to enroll patients as soon as reasonably possible while they are waiting to be onboarded to the billing system. Then once they are onboarded to the billing system, they can roster all those enrolled patients on the first day.

Patients will be automatically de-rostered from the Blended Capitation billing system and capitation payments for them will stop upon:

  • admission to a Long Term Care Facility, meaning a publicly-operated long-term care facility providing on site professional health and nursing services;
  • the patient’s death;
  • removal from the Roster by the physician;
  • an expired MCP number (card);
  • an invalid MCP card;
  • federal incarceration;
  • a patient has been rostered by another physician;
  • or a physician’s roster limit has been reached.

MCP will send physicians an EMR message indicating that a patient has been de-rostered and the reason why. Please review the eDOCSNL Tipsheet for more information about de-rostering.

If a newborn is receiving care from the provider before they have their own MCP, they cannot be rostered under the Blended Capitation Model and are billed under their mother’s MCP. Once the baby has their own MCP they can be rostered and billed under the Model. Until the baby gets their own MCP card there is no associated capitation payment.

Per Schedule R, patient attachment must be confirmed (via the enrollment process) before they are rostered to the BC billing system.

Accepted Blended Capitation physicians are encouraged to enroll patients as soon as reasonably possible, at a pace that works for their practice, while they are waiting to be onboarded to the billing system. Then once they are onboarded to the billing system, they can roster all those enrolled patients on the first day.

When a date for onboarding is suggested by eDOCSNL, BCGs are expected to schedule their onboarding within a reasonable timeline from that date (i.e., there will be 2-3 weeks during which the BCG can pick their onboarding date) regardless of how many patients they have enrolled.

Please note, patients must be enrolled before they can be rostered (attachment is a requirement of Schedule R).

No. Enrolment is the formal process to confirm attachment between a patient and their primary provider. Unless a patient is a child under 16 years or a dependent adult, they must agree to enrollment themselves.

Groups that have been accepted into the Blended Capitation Model may telephone patients to conduct the enrollment process or enroll patients when they come into their office for an in-person appointment. The Information sheet can be read to the patient over the phone and the patient’s confirmation of enrollment can be given verbally and recorded in the electronic Patient Enrollment Form in Med Access. Patients’ confirmation of enrollment (signatures are not required) can also be received via secure email but will have to be manually entered into the electronic Patient Enrollment Form in Med Access.

Physicians may roster patients at whatever speed makes sense given the nature of their practice, but are encouraged to roster patients as soon as reasonably possible. All patients should be rostered within 2 years from a blended capitation group’s acceptance date into the model, during which time the group’s members are eligible for the guaranteed income floor. At the end of the 2-year income floor period, non-rostered patients can be billed @ 100% FFS up to a maximum of $56,000 annually for in-basket services (per Schedule R, section 3.9). Out-of-basket services for non-rostered patients can still be billed 100% FFS (no cap).

Service Expectations

The Group must be committed to using its best efforts to provide its Roster of patients availability and timely access to excellent team-based primary care. The Group will establish, based on the primary care needs of its Roster, a schedule for the regular weekly availability of non-emergency priority care. This does not mean that every physician within the Group must work Monday through Friday, 9 am to 5 pm. Rather, it means that regular availability must be established each week in relation to Roster size, with recognition that physicians may set aside time for other medical activities, administrative activities, or have a part-time practice. See Section 8 in the BCM Policy Guide.

Physicians who work part-time (e.g. two days a week with a roster size of 400 patients) may still enroll in the Blended Capitation Model as long as they provide comprehensive longitudinal services to their roster and meet access indicators. Physicians within the group may be part time as long as there is “reasonable, regular hours each week of the year”, including the required after-hours access, which can be shared among the overall group.

The after-hours requirement does not require more hours of work per week.  It only requires the group to schedule a portion of its work outside the 9-5, Monday-Friday window.

There is a formula for the number of hours per week of after-hours care linked to the total number of rostered patients.  For example, a group with 3,600 patients must provide a minimum of 6 hours of after-hours care each week. This obligation is divided among the doctors within the group (e.g., for three doctors it could mean 2 hours each per week, or 6 hours per doctor for one week out of three).  The after hours requirement increases in proportion to the number of patients attached to the group. See Section 3.5 (c) in Schedule R.

This is a decision of the group, and will be guided by FPRC policy. Here are some examples:

In a group of three physicians serving 3600 patients, the obligation is 6 hours per week for the whole group.

  • Option 1: The physicians choose to take turns providing a Saturday clinic on rotation (one Saturday every third week for 6 hours). When a physician provides the Saturday clinic they can book one of their regularly scheduled clinic days off, to maintain a normal workload.
  • Option 2: On two days a week each physician might open at 8:00am or close at 6:00pm.  They can also keep the same number of total hours each day to maintain a normal workload.
  • Option 3: Every week there is a Wednesday clinic from 5-8pm and a Saturday clinic from 9am to 12noon, for a total of 6 clinics every three weeks.  Each of the physicians may cover two of the clinics in a three week period, and take time off during the week to maintain a normal workload.

In a group of four physicians serving 4000 patients, the obligation is 6.8 hours per week for the whole group. If three physicians have panels of 1200 patients each, and the other physician has a panel of 400 patients, the physicians can choose to divide the after-hours expectation according to their patient loads.  For example, once a week each of the three physicians with larger panels could stay open two extra hours, and the physician with the smaller panel could extend by one hour.  To accommodate for the later hours, they could adjust the start time of their workday.

The expectation is that doctors in a group will make their after-hours care available to all the patients attached to physicians within the group.

Yes. Any appointments outside the regular hours of Monday to Friday, 9:00 am to 5:00 pm, meet the after-hours requirement.

No,  only NPs employed by or directly contracted by the BCG count.

The objective of the performance indicators process is to encourage continuous improvement and/or maintenance of accessibility and high-quality care. If a Group (or an individual physician within a Group) is not maintaining accessibility or quality of care, consistent with the above objective, based on the performance indicators, the FPRC will engage the Group or the physician in a process of information exchange and performance improvement. If, following these activities, improvement has not been achieved, the FPRC will have discretion to terminate the Group (or an individual physician within a Group) from the Program. Please see Section 3.6(d) of Schedule R.

This function sits with FPRC. Section 3.6(e) of Schedule R sets out FPRC’s role to develop definitions and guidelines for the performance indicators, and Section 3.6(f) to monitor them.

For the first two years of the program, groups that already provide regular, ongoing provision of services to the NL Health Services, such as hospitalist services, primary care services for unattached patients, hospital emergency room coverage, anesthesia services, obstetric services, and long-term care services, will be permitted to redistribute their after-hours service obligations to the Group’s nurse practitioner (NP) or, if the Group has not hired an NP, to seek an exemption from the Blended Capitation after-hours requirement. Groups may apply to the FPRP to determine if members of the group qualify for exemption. For a physician to qualify, they must be providing at least two hours of the types of services described above to NLHS for every one hour of after-hours BCM service exempted or redistributed. Groups that do not provide any of the types of services outlined above do not qualify for the exemption/redistribution.

This exemption will be in effect until August 31, 2025.

An application will be developed at a later date and communicated to BCM applicants who wish to apply for this exemption.

The full amendment to Schedule R is available here.

No, this is not a requirement of Schedule R 3.5(c.1) as long as it is NLHS Service.

Under the model, patients commit to seek primary care from their physician and the physician commits to providing comprehensive continuous primary healthcare services across the life span of their patients, based on patient needs and responsive to documented needs of the geographic community they serve. (see section 3.3 of Schedule R). Section 3.5 further defines expectations and coordination with other members in the group.

Section 3.5 (c.1) outlines the Redistribution/Exemption available for After-Hours Expectations until August 31, 2025 for those physicians providing ongoing services to NL Health Services. Hospital and emergency room coverage are two examples of NLHS services that can exempt physicians from the after-hours requirement, in recognition of the importance of this specific service to the system. The exemption is intended to support physicians to continue to provide that service while transitioning to the new payment model for their community practice.

The after-hours requirement starts on the date the Blended Capitation Group is onboarded to the billing system.

FTE equivalency is only used to calculate the income floor for physicians without a 2-year billing history. For those physicians, the amount of FTE of comprehensive primary care that will be required to qualify for payment under this section will be determined according to the number of three-hour community medicine blocks provided per week, on average over a four-week period (i.e. 1.0 FTE = 27 hours of community-based primary care; 0.8 FTE = 21 hours of community-based care).

For physicians with a two-year billing history, the income floor will be established using two recent representative years per section 3.12 of Schedule R.  However, if you have recently, or soon plan to, reduce the size of your community-based practice, or otherwise expect a reduction in your billing income, please indicate that you do not accept the Income Floor on the form. You will be contacted by the Blended Capitation Advisor to develop a solution customized to your circumstances.

The Basket of Services and after-hours care may be provided in-person or virtually, as determined appropriate by the provider. CPSNL standards of practice apply regarding virtual care and the use of virtual care is regulated by the College.  As well, there is currently a 40 unit cap on the number of virtual visits that may be billed per day, per MCP billing rules.

The objective of the Performance Indicators is to encourage continuous improvement and/or maintenance of accessibility and high-quality care. Capitation payments will not be withheld due to occasional or infrequent instances of unmet service expectations.

However, if the FPRC considers that a group or a physician is not maintaining accessibility or quality of care, consistent with the set expectations, the FPRC will engage the group or the physician in a process of information exchange and performance improvement.

If following such engagement, the FPRC concludes that the necessary improvement has not been achieved, the FPRC may in its discretion terminate the group or an individual physician from participation in the Program. Please see the BCM Policy Guide.