Payer Mix

What is Payer Mix?

Payer mix describes the proportion of a practice's or hospital's patient volume and associated revenue attributable to each payer category. Reimbursement rates differ dramatically by payer: Medicare typically pays approximately 80% of the allowed charge for most services; Medicaid pays 50–70% of Medicare rates in most states (with wide variation); commercial insurance pays 150–300% of Medicare (depending on market concentration and contract leverage); and self-pay patients are typically collected at 20–30% of billed charges or less. A practice with 40% Medicaid versus 20% Medicaid has fundamentally different revenue per visit even when providing identical clinical services. Payer mix shift analytics track month-over-month changes in payer distribution — Medicaid expansion effects, Medicare Advantage penetration growth, and employer-sponsored insurance trends all create payer mix shifts that affect financial performance without any change in clinical volume. Common benchmarks: safety net hospitals often carry 30–40% Medicaid; suburban specialty practices may have 5–15% Medicaid; Medicare Advantage now represents 51%+ of Medicare nationally.

Why It Matters for Healthcare Analytics

Payer mix is the single most powerful determinant of revenue per visit, yet it often changes gradually and goes undetected until financial performance has already deteriorated. Tracking payer mix by service line, provider, and clinic location — and projecting revenue impact of mix shifts — allows leadership to make proactive decisions about access policies, contract negotiations, and service line investments before revenue impact materializes.

How Vizier Tracks Payer Mix

Upload your claims data and ask "How has our payer mix shifted by service line over the past 12 months, and what is the revenue impact?" — Vizier calculates payer distribution changes, quantifies the revenue per encounter by payer, and projects the financial impact of current mix trends.