Payer Mix - RCM Metrics - MD Clarity (2024)

FAQs

What is the formula for payer mix? ›

To calculate Payer Mix, the total revenue received from each payer type (such as Medicare, Medicaid, commercial insurance, self-pay, etc.) is divided by the total revenue received from all payer types. The resulting percentage represents the proportion of revenue generated by each payer type.

Boost your bottom line by automating patient cost estimates, payer underpayment detection, and contract optimization in one place.

Percentage of A/R over 120 days Benchmark

The industry standard benchmark for Percentage of A/R over 120 days is typically around 10-15%. This means that healthcare organizations aim to keep their A/R over 120 days at or below this benchmark.

Target high-value patients.

High-value patients improve your healthcare payer mix as you identify and target those with the right private insurance, those who are self paying, or whichever patients will give you the highest return.

What is payor mix? Payor mix measures patients who have federal health insurance, such as Medicaid and Medicare, compared to patients who pay themselves or have private medical insurance. Accordingly, payor mix tracks which payor funds healthcare costs.

The Case Mix Index (CMI) is the average relative DRG weight of a hospital's inpatient discharges, calculated by summing the Medicare Severity-Diagnosis Related Group (MS-DRG) weight for each discharge and dividing the total by the number of discharges.

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Clarity has been building HIPAA-compliant portals and marketplaces for over 10 years.

The Clarity database is a large subset of data that comes from the PennChart (Epic) application. The data is transferred from the PennChart Chronicles database to Clarity, a Microsoft SQL Server database comprised of over 18,000 tables, in a load called the ETL (Export, Transform, and Load).

But how do you track, report on, and optimize RCM? Enter key performance indicators, or KPIs. Our seasoned revenue cycle management experts, with a collective experience of 50 years, have selected the 20 most influential KPIs for medical providers, encompassing the entire RCM process from patient scheduling to payment.

What is the average AR over 90 days? ›

Accounts/Receivable Greater than 90 Days is a Key Benchmark

Based on industry data, an A/R>90 in the 15-20% range is average, so if you are much higher than that number, you likely could benefit from working with a medical billing company like Outsource Receivables, Inc.

Action: Consider establishing a target AR range for your practice. For example, you might shoot for having 60 percent of receivables fall into the 0-30 days bucket, 20 percent in 31-60 days, 5 percent each at 61-90 days and 91-120 days, and 10 percent falling over 120 days.

Significant changes in payer mix will alter a practice's collection ratio and may result in a reduction of net revenue. Practices with a significant shift away from commercial insurance to Medicare or Medicaid generally will experience an overall decrease in revenue.

It is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges. CMIs are calculated using both transfer-adjusted cases and unadjusted cases.

Case mix, also casemix and patient mix, is a term used within epidemiology as a synonym for cohort; essentially, a case mix groups statistically related patients.

Regardless of the mechanism, payer mix is generally considered an important component of a hospital′s financial health; for example, by increasing revenue through higher reimbursem*nts from commercially insured patients and those covered by Medicare compared to uninsured patients and Medicaid participants.

Third-party policies can impact the payer mix for maximum reimbursem*nt in a number of ways. For example, some third-party payers may have higher reimbursem*nt rates than others. This can lead to a higher percentage of patients being covered by these payers, which can improve the payer mix.