Have you ever wondered how Wellmark pays providers? It’s interesting to understand what goes into payment arrangements and how that usually results in savings for you.
Maximum allowable fee
The maximum allowable fee is the amount, established by Wellmark, using various methodologies, for covered services and supplies. Wellmark’s amount paid may be based on the lesser of the amount charged for a covered service or supply or the maximum allowable fee.
Payment arrangement savings
Wellmark has contracting relationships with PPO or Network providers. We use different methods to determine payment arrangements, including negotiated fees. These payment arrangements usually result in savings. The savings from payment arrangements and other important amounts will appear on your Explanation of Benefits statement as follows:
Payment method for services
Provider payment arrangements are calculated using industry methods, including but not limited to fee schedules, per diems, percentage of charge, capitation*, or episodes of care. Some provider payment arrangements may include an amount payable to the provider based on the provider’s performance. Performance-based amounts that are not distributed are not allocated to your specific group or to your specific claims and are not considered when determining any amounts you may owe. We reserve the right to change the methodology we use to calculate payment arrangements based on industry practice or business need. PPO, Network and participating providers agree to accept our payment arrangements as full settlement for providing covered services, except to the extent of any amounts you may owe.
*Capitation is payment to health care providers contracting with Wellmark Health Plan of Iowa for certain services according to a uniform amount per patient.