What Medical Billers and Coders Need to Know About Individual Payers

By Karen Smiley

When you hear the term individual payers, you may assume it refers to individuals, but it doesn’t. Individual payers are actually the insurance companies that provide group and individual coverage plans to patients. Each payer has its own policies and procedures, which are published and available for both patients and providers to review.

The payer may be a plan administrator that is part of a pricing network or may serve as administrator for sponsored plans.

More often than not, CMS sets the bar when it comes to payer rules. Medicare follows a strict set of claims‐processing policies that include correct coding edits, mutually exclusive procedures edits, modifier requirements, unit requirements, and numerous other specifications. In addition, Medicare allows claims to be submitted within 12 months. Individual payers may follow the Medicare rules for payment, but they don’t have to follow them. In fact, many often have their own policies.

Individual payers employ their own processing policies, including which edits they follow, which modifiers they recognize, and other payer‐specific rules. As the coder and biller, you must be knowledgeable about each payer’s policies when you prepare a claim for submission. If you don’t follow the payer’s policies, the claim may pay incorrectly or not at all.

In addition, most commercial payers have much shorter timely filing requirements than Medicare’s 1‐year limit, usually 90 days — which isn’t a long time when crucial documentation is missing!