Why Building a Patient Panel is Harder Than It Looks
Alina Mineyli, Credentialing specialist at WCH
Recently, one of our clients approached us with a concern. After joining an IPA and securing a capitated basis contract, the provider enrolled with several insurance plans and, over time, noticed they were not receiving the expected incentive payments as a PCP. Under the capitated arrangement—according to the specific line of business—the provider is supposed to receive a per-member fee for each attributed patient, regardless of whether a visit occurred. However, no incentive payments were received.
The Numbers Game: What Solo Practitioners Need to Know
We discovered through follow-up with the insurance company that, as it turns out, a provider must have at least 300 patients assigned as their PCP panel in order to qualify for incentive bonuses.
Here's what they don't always tell you upfront: those 300 patients required for bonuses represent a significant commitment—especially for solo practitioners. For a solo provider, managing 300 patients from a single insurance plan can consume approximately 70% of their practice capacity.
This creates a difficult bind. The provider cannot realistically accept additional insurance contracts, as this one plan already occupies the majority of their time and clinical bandwidth. And if the insurance company is unable to assign enough patients in the provider's area to meet the 300-patient threshold, the provider receives only the basic capitated payment—with no opportunity to earn incentives—while being effectively blocked from pursuing bonuses through other payers.
In practice, the provider is left operating nearly full-time for a single insurance plan, without any guarantee of reaching the volume needed to unlock incentive payments. It can feel like working 24/7 for one payer—on someone else's terms.
Understanding the Capitated Model Challenge
This scenario illustrates a common issue with capitated contracts through IPAs. Providers often enter these arrangements expecting to receive both the per-member capitated fees and incentive bonuses, similar to what they might earn through direct contracts with smaller patient panels.
However, the reality is that reaching the 300-patient threshold required for bonuses can be extremely difficult, particularly in certain geographic areas where the insurance company may not have sufficient membership to assign to a single provider. Without reaching this minimum panel size, the provider is left with only the basic capitated payments while being unable to pursue more lucrative opportunities with other payers due to the time commitment required.
Critical Questions to Ask Before Signing
Before entering into any IPA contract, providers should ask several essential questions:
About Incentives:
How exactly will I receive incentive payments?
What are the specific patient volume requirements for bonuses?
How realistic are these numbers for my practice size and location?
About Patient Flow:
How will the insurance company provide patients to my practice?
What is the expected timeline for reaching required patient volumes?
What happens if patient volume targets aren't met?
About Administrative Requirements:
What documents must I submit to the insurance company?
How frequently will medical records be requested?
What are the administrative time commitments?
About Practice Impact:
Can I maintain contracts with other insurance plans?
What percentage of my practice capacity will this contract require?
How will this affect my ability to serve fee-for-service patients?
Making an Informed Decision
Understanding these factors helps providers weigh the pros and cons of IPA contracts versus direct contracting. With direct contracts, providers typically receive fee-for-service payments and can maintain more control over their patient mix and schedule.
The key is making an informed decision based on realistic expectations rather than optimistic projections. Some providers thrive in capitated models with large patient panels, while others find more success and peace of mind with smaller, direct-pay practices.
The Bottom Line
Understanding the true requirements and limitations of capitated contracts is crucial for making informed business decisions. The economics of different contract types significantly affect practice growth and revenue potential.
Whether you choose the IPA capitated route or direct fee-for-service contracting, success depends on thoroughly understanding the commitment required and having realistic expectations about patient volume and revenue timelines.
The most important step is conducting proper due diligence before signing any contract. This ensures your choice aligns with your practice goals, capacity, and geographic market realities, leading to better outcomes for both your practice and your patients.