Create a payer matrix in 13 easy steps

 Erika Regulsky Tags: , , Practice Management

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Payer matrix checklist for medical practices!

Did you know that a hospital works with 1300 insurers on an average? And the fact that every insurer has different plans and regulations makes the insurance billing process extremely complex and ridden with tripwires. Has your medical practice been discussing about maintaining a payer matrix off-late? If not, it is high time you did.

Tracking the payment pattern of insurers, identifying underpayments, weeding out insurers who repeatedly deny or underpay claims is a tedious process. A payer matrix can help resolve revenue cycle issues and enable physicians to negotiate better fee-schedules.

Download the resources on 7 practice management templates which need zero technical skills

Here is a small checklist of what your payer matrix should consist of…

  1. Contact information of contracting and credentialing representatives
  2. Name and contact details of all your payers
  3. The basic agreement structure of all contracts
  4. Termination/renewal dates of contracts
  5. The coverage and documentation guidelines of payers
  6. The deadlines and pre-authorization, pre-determination requirements of payers
  7. The reimbursement rate for your medical practice’s major CPT codes
  8. The first pass claim acceptance rate of insurance companies
  9. Utilization guidelines for each contract
  10. The average turnaround time of each payer
  11. Payment policies for services rendered by physician assistants
  12. The exclusions and inclusions of payable services
  13. The claim appealing process/window of insurers
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The next step:

Accurate data is just the means to an end. A majority of medical practices fail to leverage data collected, into meaningful and productive measures. Once you put together your payer matrix it is essential that you analyze the information at hand and take firm steps towards bettering your revenue cycle.

  • Analyze the number of times claims have been turned down due to non-compliance with utilization guidelines or authorization requests. Request explanations and remedial steps from your billing department
  • Maintain a simple database for each payer and spot the discrepancies in payment for the same set of CPT codes.
  • Set up a negotiation schedule and follow-up diligently till underpayments are resolved
  • Fix clear deadlines for submitting claims and appealing denials
  • Stop working with insurers who repeatedly underpay and make sure your patients are informed of the decision
  • Too taxing and time-consuming? Automate the entire process. There are several smart applications that can help you keep tabs on payer data, and, update your payer matrix, quickly and efficiently.
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I’m a multi-certified revenue cycle management professional and compliance officer with 20+ years of experience. I contribute articles to leading healthcare publications and journals. I am currently working as Senior Transition Manager, in BillingParadise headquartered at Diamond Bar, California. BillingParadise offers Medical Billing Services that intersect perfectly with the EMR/Practice management system you use.BillingParadise has offices in New Jersey, New York, Florida, Georgia, Minnesota, and Texas.


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