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Practice Planning Tool

See what reimbursement mix does to the practice

Payer-Mix Sensitivity

Estimate how changes in commercial, Medicare, Medicaid, self-pay, and other patient volume may affect collections, operating contribution, and the completed visits needed to break even.

✓Weighted collections per completed encounter
✓Revenue and break-even impact of a payer shift
✓Capacity, margin, and concentration decision checks

What must each completed encounter help support?

Enter completed visits and the practice costs that must be covered each month. Use collections—not charges, billed amounts, or contractual allowed amounts that the practice does not expect to receive.

Volume and capacity

Completed encounters
visits
%

Used to translate completed-visit targets into scheduled appointments.

visits

Use the Provider & Staffing Capacity Tool if this is uncertain.

Cost and margin assumptions

Monthly practice economics
$
$
%

Used as an editable planning goal, not an industry guarantee.

Payer mix affects more than top-line revenue. A lower collected amount per encounter increases the volume required to support the same staff, space, technology, debt, and owner compensation—even if the schedule looks full.

What does the practice expect to collect from each group?

Enter the percentage of completed encounters and the average amount actually collected per encounter. Use actual remittance history or contract-supported estimates whenever available. All mix percentages must total 100%.

Current or expected payer mix

Editable starting assumptions
Commercial / employer coverage ?Employer plans, individual commercial plans, and contracted commercial products.
%
$
Original Medicare ?Traditional Medicare fee-for-service; exclude Medicare Advantage encounters.
%
$
Medicare Advantage ?Private Medicare plans, entered separately from Original Medicare.
%
$
Medicaid / CHIP ?State fee-for-service and managed Medicaid or CHIP products.
%
$
Self-pay / direct pay ?Patients or organizations paying the practice directly without insurance adjudication.
%
$
Other programsTRICARE, workers' compensation, employer-direct arrangements, grants, or other encounter-based sources.
%
$
Total entered payer mix100%
Do not use billed charges as reimbursement. The useful input is the net cash the practice expects to retain per completed encounter after contractual adjustments, denials, patient responsibility that is not collected, refunds, recoupments, and other normal leakage.

What change do you want to test?

Shift a percentage of completed encounters from one payer category to another, then optionally apply a collection-rate change to the entire scenario. The baseline volume and cost structure remain unchanged so the payer effect is visible.

Modeled payer shift

Percentage points, not percent change
points

Collection sensitivity

Optional additional stress
%
days

Used only to translate monthly break-even volume into a daily target.

A payer shift may create an operational effect before it creates a visible loss. More visits, authorizations, eligibility work, documentation, denials, patient collections, or payment delay may be required to produce the same cash. This calculator models cash per encounter; it does not model every administrative difference among payers.

Review the assumptions before relying on the comparison

Confirm the completed volume, costs, payer percentages, net collected amounts, capacity, and scenario shift. The result is a planning sensitivity—not a fee schedule, contract analysis, or forecast of payer behavior.

Payer-mix sensitivity result

The comparison holds completed volume and entered costs constant.

Baseline collected / visit—Weighted by the entered mix
Scenario collected / visit—After payer shift and rate change
Monthly collection change—At the same completed volume
Annualized cash impact—Monthly difference × 12

Baseline mix

Current or expected payer assumptions before the sensitivity test.

Monthly collections—
Operating contribution—After entered fixed and variable costs
Cash break-even——
Visits for desired margin——
Capacity check——

Modeled scenario

Payer shift and collection sensitivity applied.

Monthly collections—
Operating contribution—After entered fixed and variable costs
Cash break-even——
Visits for desired margin——
Capacity check——

Payer contribution comparison

Monthly collections attributable to each category at the entered completed volume.

Rounded planning estimates
Payer categoryBaseline mixScenario mixEntered collected / visitBaseline monthly collectionsScenario monthly collections
Important: This educational planning tool provides estimates based solely on user-entered assumptions. It is not a payer-contract analysis, fee schedule, reimbursement quote, actuarial analysis, valuation, feasibility study, financial forecast, coding or billing determination, or legal, tax, accounting, compliance, credentialing, clinical, or other professional advice. It does not determine coverage, medical necessity, network participation, authorization, coding, claim acceptance, patient responsibility, payment timing, recoupment exposure, or the amount any payer or patient will pay. Actual reimbursement and collection performance vary by contract, plan, state, service, code, site of service, provider type, documentation, patient benefits, billing performance, and other factors. Verify assumptions using current contracts, fee schedules, remittance data, and qualified advisors before making a business decision. Do not enter protected health information or other confidential information.
Planning references: CMS Physician Fee Schedule Search · CMS CY 2026 PFS Summary · Medicaid Payment-Rate Information