Impact of Payer Mix Shift on Orthopedic Practice Payments

Billing & Reimbursement Health Information Services Medical Coding Orthopedics

Impacts_of_Payer_Mix_Shift In order to maintain a healthy revenue stream, it is key that your practice has a well-balanced mix of payers. If your revenue stream seems to be sagging it could be that your payer mix has shifted in a negative direction. That is, you may have seen patients with coverage from lower, poor, or slow payers.  Here are some things you can do to address that situation.

First, break down your patient list into the payers by whom they are covered.  You will likely find that the most common groups of payers are government agencies such as CMS (Medicare and Medicaid); commercial carriers like Aetna, Blue Cross Blue Shield, CIGNA, Humana and others; Worker’s Compensation,  legal claims, and self pay.  You should also identify, and be paying attention to, plans obtained through the Health Insurance Exchange marketplace created by the PPACA.

Each of these payer groups have particular policies and procedures associated with payment rates, promptness of payments and coverage of services. 

Once you’ve identified your payer mix and the areas in which it could use improvement, there are steps you can take to create a favorable shift in your payer mix.

  • Check your online presence
    • Make sure your website lists the insurance carriers you accept, placing the favored carriers and/or ones you wish to increase your business with at the top of the list.
    • Also, check the websites of carriers who you accept and be sure you’re listed as in-network on those sites.
    • Have this information updated twice a year.
  • Reach out to your referrers
    • Be sure your referring physicians have a list of the carriers with whom you work so they know who you can accept as a referral. 
  • Limit your low-paying patients
  • Market yourself
    • Focus on marketing your practice to the community and to physicians who can refer the desired patients to you.
    • Reach out to them and let it be known that you’re accepting new patients – it can’t hurt to be front-of-mind when it comes time for them to make a referral.

Taking the time to identify your payer mix and taking the steps which will shift that mix in a more favorable direction will yield results. None of these methods are high-cost, and yet all of them applied in tandem can contribute to a much healthier bottom line for your practice.


ourtesy via Stuart Miles/