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Payer contract modeling for health systems

Model payer terms.See the reimbursement impact.

Compare proposed terms on the same claims. See which provisions change the result.

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A higher rate is only part of the picture.

Change the case rates, add a stop-loss provision, or combine both. See how the terms work together—and why some claims change while others do not.

Sample contract comparison

Sample inpatient cohort

Modeled allowed reimbursement

3 of 4 claims priced in both scenarios

Baseline
$38,000
Proposed
$41,000
Modeled change
+$3,000+7.9%

Totals include only those 3 claims.

Select a proposed contract scenario

Claim comparison

4 selected claims

Select a claim to follow the calculation.

Baseline and proposed modeled allowed reimbursement for four sample inpatient claims.
ClaimBaselineProposedChange
$10,000$11,000+$1,000
$20,000$22,000+$2,000
$8,000$8,000$0
———

A 10% case-rate increase produces a 7.9% increase in modeled reimbursement across the three priced claims. The lesser-of provision keeps the charge-limited claim at $8,000.

How this amount was calculated

Priced

Surgical admission

$35,000 billed charges

Scenario terms

Increase case rates by 10%, then apply lesser-of billed charges.

  1. Case rate

    $20,000 × 1.10 = $22,000

  2. Lesser-of billed charges

    min($22,000, $35,000) = $22,000

Modeled allowed reimbursement$22,000

+$2,000 against the baseline

Illustrative terms and claims. Modeled results are not payer-reported allowances or actual payments.

For hospital contracting and finance teams

  • Managed care
  • Reimbursement analysts
  • Healthcare finance

How Multiplayer works

Test the contract questions your team needs to answer.

What would a rate increase change? Where does a threshold matter? Compare proposed terms, then examine the claims and provisions behind the difference.

  1. Set the comparison

    Start with the terms and claims.

    Choose baseline terms and a fixed set of claims. Define the provisions you want to change.

  2. Test the proposal

    Compare proposals without losing your baseline.

    Apply a proposed rate or threshold to the same claims. Keep each comparison with its inputs and assumptions.

  3. Explain the result

    Understand what drives the difference.

    Follow the claim-level calculations. See which provisions drive the difference and which claims could not be priced.

From baseline to proposalIllustrative comparison

  1. Baseline

    Original terms · Fixed claim population
    $38,000

  2. Case-rate proposal

    Case rates +10% · Same claims
    $41,000

  3. Combined terms

    Rate change + stop-loss · Same claims
    $42,000
4 selected claims3 priced in every comparison
Modeled allowed reimbursement for the same three priced claims. Each run retains its inputs and assumptions.
See the inputs behind the result
Inputs for one sample claimAuthored example

  1. Contract terms

    A $10,000 case rate, limited to billed charges.

  2. Claim

    $12,000 in billed charges for an inpatient admission.

  3. Payer adjudication

    Payer-reported allowance: $10,000. Payer-reported payment: $8,000. Patient responsibility: $2,000.

  4. Posted insurer payments

    Two sample cash postings of $6,000 and $2,000.

Original records remain separate from hypothetical changes.

See the proposal alongside what the payer reported and paid.

In this sample, the proposal changes modeled allowed reimbursement. The reported allowance and posted insurer payments retain their original amounts.

Authored financial example1 inpatient claim · Fixed case rate
Proposed contractModeled allowed reimbursement
$11,000

Payer adjudication

Payer-reported allowance
$10,000
Payer-reported payment
$8,000

Allowance reconciliation

Payer-reported payment + patient responsibility

$8,000 + $2,000 = $10,000

Payment history

Posted insurer payments2 cash postings: $6,000 + $2,000
$8,000

This sample contains no patient cash postings.

Inpatient reimbursement

See how contract provisions change the result.

Model inpatient reimbursement using case rates, percent of charges, per diem, stop-loss, and lesser-of provisions. Define the rate basis, payable days, thresholds, and application order required by the agreement.

Case rates
A defined amount per qualifying case, with the applicable scope and exclusions.
Percent of charges
A percentage of eligible charges, with included and excluded services defined.
Per diem
A rate applied to payable days, using the day-count convention specified in the agreement.
Stop-loss
A defined threshold and payment basis, with first-dollar or excess-dollar treatment and add-or-replace behavior made explicit.
Lesser-of
A comparison of specified amounts, applied at the step required by the contract.

Getting started

What happens in the first walkthrough?

We compare a case-rate increase, a stop-loss provision, and both together using illustrative inpatient claims. Select a claim, follow its calculation, and see how billed-charge limits and missing data affect the results. Bring a contract question your team wants to test.

Do we need to prepare or upload claim files?

No files are needed for the sample walkthrough. It uses four authored inpatient claims, including one with missing billed charges. You can explore the comparison on this page without a claims extract, contract upload, or data connection.

How are the sample contract provisions entered?

Choose Case-rate proposal, Stop-loss add-on, or Combined terms. The presets begin with a 10% case-rate increase or a stop-loss add-on of 20% of charges above $30,000. Adjust the case-rate increase or stop-loss threshold to explore the result. The lesser-of provision limits modeled reimbursement to billed charges.

Which reimbursement methods are in scope?

Multiplayer focuses on inpatient reimbursement, including case rates, percent of charges, per diem, stop-loss, and lesser-of provisions. The sample comparison demonstrates case rates, stop-loss, and lesser-of. During a demo, we can review the specific provisions your team needs to model and discuss any limitations.

How do unpriced claims affect a comparison?

Unpriced claims remain visible but do not contribute to the comparison totals. Both scenario totals use the same set of claims priced in both scenarios, and the comparison shows how many selected claims were excluded.

Let's talk about your team's work

What contract question is your team trying to answer?

Tell us a little about your team and the contract questions you want to answer. We’ll follow up to arrange a walkthrough.

Please do not include patient information, claim records, or confidential contract terms.

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