Skip to main content

Set up a payor

A payor is the person, company, plan, or program responsible for paying for all or part of a patient's care. Payors are used when you add patient coverages, set up billing episodes, track authorizations, and review billing information.

Before you start​

You need:

  • An organization. See Set up an organization.
  • Admin access to add a payor.
  • The payor name, type, and payment model type.
  • Patient-specific benefit details if you also plan to add a coverage after creating the payor.

Medicare Part A and Medicare Part B are pre-loaded in new organizations, so you do not need to create them manually.

Choose a payor setup workflow​

There are two ways to set up a new payor in RehabAlpha:

  • Manual setup: Add the payor directly in RehabAlpha. Use this workflow when you are entering one payor or want full control over the payor name and type as you create the record.
  • Import: Upload one or more files with payor information using the import tool. This is explained in Import data.

The steps below explain the manual setup workflow.

Manually create a payor​

  1. Open Payors.
  2. Click New payor.
  3. Enter the payor Name.
  4. Select the payor Type.
  5. Select the Payment model.
  6. Add tags or notes when helpful.
  7. Click Save.

RehabAlpha creates the payor and adds it to the organization's payor list.

The payment model type defines one reimbursement or benefit lane:

  • PDPM case-mix per diem uses a daily case-mix calculation.
  • Custom fee schedule uses an uploaded organization fee schedule.
  • Duration-based payment pays a configured amount per minute for each discipline.
  • Medicare Part B MPFS uses the CMS Medicare Physician Fee Schedule.

RehabAlpha initially selects PDPM case-mix per diem for Medicare Part A and Managed Care Part A payor types and Medicare Part B MPFS for Medicare Part B and Managed Care Part B. It initially selects Custom fee schedule for every other payor type. You can change that selection before creating the payor. Imported payors use the same defaults when the source data does not specify a payment model type. These are defaults only; every payor type supports every payment model.

Choose carefully. The payment model type cannot be changed after the payor is created. If the same carrier offers both types of reimbursement, create a separate payor record for each benefit lane.

Choose the payor type​

Choose the Type that best describes how the payor should be handled in billing and reporting workflows.

  • Use Commercial Insurance for standard commercial plans.
  • Use Managed Care Part A or Managed Care Part B for managed Medicare plans.
  • Use Medicaid for Medicaid payors.
  • Use Medicare Part A or Medicare Part B only when you need a separate Medicare-related payor record beyond the pre-loaded options.
  • Use Private Pay when the patient or another private party is responsible.
  • Use Workers' Compensation for workers' compensation coverage.

The payor type helps RehabAlpha apply billing rules and group payors for reporting.

Understand payors and coverages​

A payor record identifies who may pay. A patient coverage record describes when that payor applies to a specific patient and what benefit details are available.

Keep the payor record focused on the payor name, type, tags, and notes. Enter patient-specific details on the patient's coverage, such as:

  • coverage start and end dates
  • deductible
  • copay
  • coinsurance
  • out-of-pocket maximum
  • authorizations

Add the payor to a patient coverage​

After the payor exists, use it on the patient's coverage record.

  1. Open the patient.
  2. Click Coverages.
  3. Click New coverage.
  4. Select the payor.
  5. Enter the coverage start date and end date when known.
  6. Add deductible, copay, coinsurance, out-of-pocket maximum, or authorization details when needed.
  7. Click Save.

Manage payor details​

  1. Open Payors.
  2. Find the payor in the list.
  3. Click the payor name.
  4. Click Details.
  5. Click Edit.
  6. Update the payor name, type, tags, or notes.
  7. Click Save.

The payment model type is read-only after creation. Existing billing episodes retain the payor name, type, and payment model type that were saved with the episode.

Add a reimbursement arrangement​

  1. Open the payor.
  2. Click Reimbursements.
  3. Click New reimbursement arrangement.
  4. Choose whether the arrangement applies to All billing providers or Specific billing providers. If you choose specific providers, select one or more.
  5. Enter the inclusive start and end dates. Turn on Way back when the arrangement has no practical start date, or Indefinite when it has no end date.
  6. Configure the payment model shown for this payor:
    • For PDPM case-mix per diem, choose whether to include wage index and variable per diem adjustments.
    • For Custom fee schedule, select an uploaded fee schedule, choose custom or Medicare units, enter the adjustment percent, and choose whether to apply assistant reductions. For custom units, configure Minutes per unit, rounding, and Pool minutes by.
    • For Medicare Part B MPFS, enter the adjustment percent and configure MPPR and assistant reductions.
    • For Duration-based payment, enter the dollars-per-minute rate for each covered discipline.
  7. Add notes or tags when helpful.
  8. Click Save.

Use All billing providers when the same reimbursement terms apply broadly. The selection also covers billing providers added later. Use Specific billing providers when different, non-overlapping groups of providers need different arrangements. During any date range, each billing provider can belong to only one arrangement for the payor. An all-provider arrangement therefore cannot overlap another arrangement for that payor. Every arrangement automatically uses the payor's payment model type.

For custom units in a custom-fee-schedule arrangement, RehabAlpha adds the minutes in each selected pool and rounds the total once before allocating whole units to its services in a consistent, deterministic order. New custom-unit definitions initially use Patient, service date, discipline, and CPT code. Pools remain separate for each billing provider and reimbursement arrangement.

You should know​

Only admins can add or delete payors.

Medicare Part A and Medicare Part B are pre-loaded in new organizations.

Do not delete a payor if it is still needed for patient coverages, billing episodes, authorizations, or reporting.

Do not create a separate payor for each patient unless the payor itself is actually different. Use patient coverages for patient-specific policy periods and benefit details.

Frequently asked questions​

Do I need to create Medicare Part A or Medicare Part B?​

No. Medicare Part A and Medicare Part B are pre-loaded in new organizations.

Where do I enter deductible, copay, coinsurance, or authorization details?​

Enter those details on the patient's coverage. The payor record stores the payor name and type. The coverage stores patient-specific dates, benefits, and authorization limits.

Can I import payors instead of entering them manually?​

Yes. Use Import when you have one or more source files that include payor information. Review imported payors before using them for coverages, billing episodes, authorizations, or reporting.

Can I change a payor type later?​

Yes. Open the payor, click Details, click Edit, update the Type, and save. Review related coverages and billing setup if the type change affects how your organization expects to use that payor.

Can I change a payor's payment model type later?​

No. Create a new payor for the new reimbursement lane. End the prior arrangement and billing episode at the cutoff, then create the replacement arrangement and billing episode with the new payor.

Can reimbursement differ by billing provider?​

Yes. Add a reimbursement arrangement for each payor and billing-provider combination that uses different rates or settings. When arrangements overlap in time, their selected billing-provider groups must be disjoint. Use effective dates when the terms change.

Can I use one payor for multiple patients?​

Yes. Create one payor record for the payor organization or responsible party, then use that payor on each patient's coverage as needed.

What to do next​

After creating the payor, configure its reimbursement arrangements and the facility's billing-provider mappings. Then select the primary payor on billing episodes; RehabAlpha uses that payor's payment model type. Add the payor to patient coverages separately when you need to track patient-specific dates, benefits, or authorizations.