Payer Matrix: A Quick-Reference Guide to Payer Contract Essentials

November 20, 2014

This matrix enables physician practices to view all the key elements of their agreements on one document.

To download this article, click here: Payer Matrix.doc

The payer matrix is one of the most basic but useful tools for successfully managing payer contracts for physician practices. A payer matrix is essentially a table that summarizes pertinent contract information for each payer.

A matrix enables physician practices to view all the key elements of their agreements on one document, typically one to two pages in length. Having a complete and updated matrix can be helpful when conducting payer negotiations or generating a list of the group’s contracted payers. Ideally, this matrix would comprise the following information:

  • Name of payer
  • Contracting representative (phone, fax, email, and physical address to communicate claims issues)
  • Credentialing representative
  • Effective date of the contract
  • Agreement structure (e.g., group, individual providers, via an independent practice association/physician-hospital organization)
  • Term of the contract and termination date
  • Payer’s percentage of the practice’s volume
  • List of payer products (e.g., commercial, Medicare, worker’s compensation)
  • Terms of payment by payer product, including effective dates of years two and three and associated rates, if applicable; and exclusions or inclusions of payable services
  • Timely filing deadline
  • Amendment provision, including the period of time for the practice to respond to proposed amendments and the consequences of objecting to proposed amendments
  • Deadlines for both parties to recover overpayments and underpayments
  • Preauthorization requirements

If such information is not readily available or complete, finding the information when challenges arise – such as determining whom to contact in the payer organization to resolve an issue – can be difficult.

Likewise, without such a matrix, it can be challenging to determine whether contract terms are fair and the practice is receiving appropriate payment.

Physician practices should consider developing a matrix for each of its payers and should regularly ensure that the matrix is current and complete.

To download this article, click here: Payer Matrix

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