Skip to main content

Set up a payor

warning

RehabAlpha is still under active development. It is not yet HIPAA compliant and should only be used with dummy data.

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.
  • Owner or Admin access, or Custom access with Create permission for Payors.

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 payor rules, AI compliance guidance, 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's identity, rules, and documentation guidance. 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​

With Custom access, you need Update permission for Payors to change these 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, rules, AI compliance guidance, 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 AI compliance guidance​

In the payor's Details, click Edit and find AI compliance guidance under Payor rules. Enter requirements from the payor's documentation policy, such as how to justify skilled therapy or which treatment-plan styles are permitted, then click Save.

RehabAlpha uses this guidance when the payor is the primary payor for a reviewed clinical document. Changes queue affected reviews for another check, including those in closed cases. Leave patient-specific information out of this field. If you leave it blank, the review uses the other available payor rules and clinical documentation.

See Review AI compliance findings to interpret concerns, risk levels, and review status.

Add a payor arrangement​

With Custom access, you need Read and Create permissions for Payor arrangements. Read is off for new members. Creating or editing an arrangement that uses Custom fee schedule also requires Read for Fee schedules. To edit an existing arrangement, you need Read and Update for Payor arrangements.

  1. Open the payor.
  2. Click Arrangements.
  3. Click New payor 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, configure MPPR, assistant reductions, and sequestration.
    • 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 payor arrangement.

You should know​

Owners and Admins can add or delete payors. Custom access can do so with the matching Create or Delete permission for 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 payor 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 payor 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.