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Medical Billers Interact with Lots of Different Payers

Most providers have contracts with multiple commercial payers (basically insurance companies), as well as government payers, such as Medicare. Here’s a very brief overview of the kinds of payers and organizations you’ll work with as a medical biller:

  • Commercial insurance: These are private insurance carriers, and they fall into a variety of categories, each of which has particular rules regarding what’s covered, when, and how providers get reimbursed. Preferred provider plans (PPOs), health maintenance plans (HMOs), and point of service plans (POSs) are just a few you’ll deal with.

  • Networks: Some commercial payers and providers participate in networks. A network is essentially a middle man who functions as an agent for commercial payers by pricing claims (that is, setting the fees associated with medical procedures) for them.

  • Third-party administrators: These intermediaries either operate as a network or access networks to price claims, and they often handle claims processing for employers who self-insure their employees rather than use a traditional group health plan.

  • Government payers: These include governmental insurance programs that offer benefits to particular groups. Examples of government payers include Medicare (the elderly and qualifying disabled people), Medicaid (the poor), Tricare (military members and their families), and so on.

What you need to know now is that each has its own rules and guidelines that must be followed to secure reimbursement. As a medical biller, you must be familiar with the eccentricities of each payer.

You never know what you might need to know about a payer, such as which modifiers are accepted, how the payer views bilateral procedures, and what kind of documentation the payer requires. Most Workers’ Compensation carriers, for example, require that procedural notes be included with all claims, even if doing so means they get the same operative report from the facility and the surgeon.

Taking the time upfront to learn what each payer requires can save you a lot of time when you’re in the groove of billing. Who wants to get tripped up by not knowing a payer’s documentation needs? Not you, rock star. So bone up on this information early and then hit your mental “refresh” button often by staying abreast of the latest payer information.

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