What is a payer matrix?

What is a payer matrix?

Within the healthcare industry, a payer (or payor) matrix is a data repository that provides information on healthcare payers. It’s used by healthcare providers, revenue cycle departments and medical billing and coding staff to store and organize information related to insurance verification, reimbursement rates, authorization requirements, claims submission guidelines, payment policies, coverage data, and information related to denials and appeals processes.

Payer Matrix is also the name of a specialty drug cost containment company, often referred to as an alternative funding company in healthcare.

What specific types of data are collected within a payer matrix?

  • Payer name and contact information
  • Type of insurance plan
  • Payment policies, rates and fee schedules for various medical services and tests
  • Coverage info on medical services
  • Info on pre-authorizations or prior approval requirements
  • Details on how to submit claims to the payer
  • Info on how to handle claim denials and submitting appeals

What are the benefits of a payer matrix?

  • Help train new employees on payer guidelines
  • Timely reimbursement and improved cash flow
  • Better decision-making on which payer network to participate in
  • Easily compare coverage and reimbursement information to assist with contract negotiation
  • Ensure that claims are filed in a timely manner and are compliant with payer requirements

How do you create a payer matrix?

After identifying the payers to be included in the matrix and gathering the relevant details, organizing the data is critical. This can be done via a spreadsheet or various software tools. Once your tool has been customized with your data, be sure to double-check the inputs for accuracy.

Once the matrix has been finalized and shared with stakeholders, it’s important to put a process in place to keep the information up-to-date and relevant to your organization.

 

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