Payer Mix Analysis Tool

Developed by PCDC in June 2023

This tool was developed in collaboration between Primary Care Development Corporation (PCDC) and the Health Information Technology Evaluation, and Quality (HITEQ) Center.

The intent of this Excel tool is to help health centers with a strategic review of their health plan contracts - across all product lines including Medicaid, Medicare, and Private/Commercial - to ensure their organization's financial sustainability and capacity to expand services to meet community needs.

The tool, available for download below, includes four tabs. Be sure to enable macros when you open the file, in the yellow banner across the top, as those are required for the tool to work as expected.

Tab 1: Health Plan (HP) Review Checklist: This checklist can serve as your initial workplan. It includes key action items for four planning stages, and enables you to identify the person responsible and due dates to help track progress.

Tab 2: Health Plan (HP) Contract Inventory: The template should be used to inventory and organize your existing/active health plan contracts. Keeping this information up-to-date and centrally organized is a key part of managing your revenue cycle and enabling regular conversation with your health plan contacts.

Tab 3: Health Plan (HP) Payer Mix Analysis: This template should leverage data pulled - from your EHR and/or practice administrative programs - to identify patient count, encounter volume, and revenue captured from each health plan business line.
Note: Make sure to include self-pay (sliding fee scale) patients in the blue row provided. Otherwise, your payer mix data may not be accurate.

Tab 4: Health Plan (HP) Payer Mix Visualizations: This template auto-updates leveraging the data provided in in the Inventory tab. This tab provides visualizations and summary tables for your health center's payer mix.
Note: Fields in yellow require data input from the health center. Fields in red are locked and will auto-populate based on your input in the yellow fields.

Disclaimer: The information contained in this tool is intended to equip health centers with general information related to planning and is not intended to replace or serve as a substitute for other tools, templates, and/or expert advice.