Payer Mix Analysis Template for Independent Practices (Free)

Most owners can name their biggest payer. Far fewer can say what share of collections it brings, how long it takes to pay, or how often it denies. KFF's Medicaid-to-Medicare Fee Index put Medicaid's average fee at 0.75 of Medicare's for all services in 2024, and 0.66 for primary care. Spread that kind of gap across every contract you hold and payer mix stops being a demographic fact. It is the price list for your week.

Share of visits is the wrong number

A payer mix report usually opens with a pie chart of visits by insurer. It looks informative and says almost nothing about money. Two payers can each bring 20% of your visits and very different shares of your cash, because they pay different rates, deny at different rates, and pay on different clocks.

The number that matters is the gap between a payer's share of visits and its share of collections. A payer whose collections share sits above its visit share is carrying more than its weight. One sitting below is being subsidized by every other patient on your schedule. You only see that gap when both columns sit side by side.

Charges are useless for this. Your chargemaster bills every payer the same amount for the same code, so share of charges mostly repeats share of visits. Collections, net of refunds, is where the contract terms finally show up.

The seven columns of a payer mix report

You need seven numbers per payer, over the same 12 months. A full year smooths out deductible season and the January plan shuffle. A single month can tell you a story that is not true.

Two rules keep it honest. Count the patient's share on a contract's claims as part of that contract, because a high-deductible plan that pays little and leaves a large balance is still that contract at work. Group by contract, not by logo, because one insurer's commercial, Medicare Advantage, and marketplace products usually pay on three different fee schedules.

A worked payer mix analysis

Picture a two-physician family practice running about 1,000 visits a month. The numbers below are invented for illustration, not drawn from any client, but the pattern is one owners tend to recognize the moment they see it laid out.

Commercial A carries the practice: 22% of visits, 29% of the cash. Medicaid managed care runs below its visit share, which fits what Medicaid pays nationally. The surprise is Commercial B, a commercial contract paying $95 a visit, less than Medicare's $110 in this example, while denying 9% of claims and taking 41 days to pay.

That row is the reason to do the exercise. Most owners assume every commercial contract beats Medicare. Some do not, especially old contracts pegged to a past year's fee schedule and never reopened. The contract you assume is profitable is the one most worth checking, because nobody has priced it in years.

Price every payer against Medicare

Collections per visit blends rate with coding and visit type. To compare contracts cleanly, price your top codes against Medicare. Take your 15 to 20 highest-volume CPT codes, list each contract's allowed amount, and divide by the Medicare allowed amount for your locality. The result is each contract's percent of Medicare, code by code.

For 2026, CMS finalized a conversion factor of $33.4009 for physicians who are not qualifying APM participants, and in November 2026 it finalized $32.6286 for 2027, a 2.31% cut (CY 2027 fee schedule final rule). Contracts paid as a percentage of current-year Medicare inherit that change automatically. Contracts pegged to a fixed past year do not move at all, which is how a contract that looked fine in 2019 drifts toward your cost.

States vary widely around those averages, and Medicaid managed care plans layer their own rates on top. Pull your state's row from KFF, then compare it with what your Medicaid plans actually paid on your top codes. The full code-by-code method, and how to carry it into a negotiation, is in the payer contract negotiation checklist.

The costs that never show on the remit

A payer's rate is only half its price. The other half is what it costs your team to get paid: prior authorizations, denials, appeals, portal logins, and hold time. None of it shows on a remittance.

In the AMA's prior authorization survey released in May 2026, 75% of physicians who work with UnitedHealthcare rated its prior authorization burden high or extremely high, the highest share of any major insurer. Premier puts the average cost to rework a denied claim at $57.23 (2023 data). Apply that rework cost to each contract's denial rate and you get a rough cost per visit the remit never shows.

Commercial B drops to about $90 a visit. Days to pay count too: a contract that takes 41 days instead of 18 keeps an extra three weeks of that contract's revenue in someone else's account. Log denials by payer and code in the denial and AR follow-up tracker so this column fills itself, and see what one denial really costs to rework for the math behind the $57.23.

Your mix moves even when you do nothing

Payer mix shifts on its own. Patients age into Medicare, move to Medicare Advantage, change jobs, or lose Medicaid at a redetermination. A mix you measured two years ago is a guess today.

The Urban Institute projects 4.9 to 10.1 million Medicaid coverage losses by 2028, tied to six-month redeterminations and work requirements starting in January 2027 (cited by MGMA Stat, July 2, 2026). On the marketplace side, HHS reported 19.2 million effectuated enrollees as of February 2026, per KFF, against 23.1 million plan selections. Patients who lose coverage still need care; they move to self-pay, to another plan, or off your schedule.

So run the workbook monthly and read the trend tab, not just this month. Two flags are worth automating. The first fires when any single contract passes 30% of collections. The second fires when any contract's share of collections moves more than 3 points in a quarter. Both are ClinicOps working thresholds, not published benchmarks.

What to do with the answer

The analysis is worth nothing until it changes a decision. It can drive four, and one comes first.

Start with the first row. Renegotiating one under-priced commercial contract changes every visit under it for the life of the contract, which no workflow fix can match. Many contracts renew automatically unless someone writes by a date, which is why the payer contract tracker exists. Any decision to limit new patients from a plan or leave a network carries contract notice terms and patient-continuity duties, so read the contract and talk to counsel first.

Three payer numbers for the owner dashboard

The owner does not need the full workbook every week. Three payer numbers belong on the monthly line of the owner dashboard, beside days in AR and denial rate.

Build the full analysis once a year, about 120 days before your biggest contract's notice window, and refresh the three numbers monthly. The dashboard itself is laid out in the owner dashboard guide, benchmark context sits in the independent practice benchmark report, and the losses this exposes are the kind described in the three leaks that never show up on your P&L.

If you would rather build it with someone, the free Leak Audit is a 15-minute look at your own numbers, and every ClinicOps price is published in full.

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