A payer refers to an organization or entity that pays for healthcare payer services, such as:

• Health insurance companies
• Government programs
  • Medicare
  • Medicaid

Payers are responsible for covering some or all of the costs associated with medical treatments and services.

What are the different types of payer services?

These are provided by organizations or entities responsible for covering or managing healthcare costs. There are types of healthcare payers and specific healthcare plans. Here are some common types of the  services:

• Insurance coverage and enrollment. It assists with enrolling in health insurance plans. It discusses the explanation of coverage options and benefits. It also verifies the eligibility for insurance benefits.
• Claims processing. It works on the receipt and processing of healthcare claims from healthcare providers. It reviews claims for accuracy and completeness. Checks the adjudication of claims to determine payment or denial.
• Member services. It provides information to members about their healthcare benefits. It assists members with questions or concerns about their coverage. Plus, it handles member complaints and appeals.
• Provider Network Management. The payer service establishes and maintains networks of healthcare providers, including:
  • Negotiating contracts with healthcare facilities and professionals.
  • Ensuring network adequacy and quality.

Healthcare payer as utilization management

The payer service works on reviewing and authorizing medical services to ensure medical necessity. The capability the tool uses is monitoring and managing healthcare utilization to control costs. It works on implementing prior authorization processes for certain services.

Premium billing and collection

Healthcare facilities have very complex paperwork that makes the handling and processing daunting, especially the billing process for salaries and insurance. Therefore, healthcare payer service works on billing members for insurance premiums. It also works on managing premium payments and collections, including handling issues related to premium payments and grace periods.

Extras of healthcare payer tool

• Compliance and regulatory services. The compliance is ensured with healthcare regulations and laws. It responds to audits and inquiries from regulatory agencies. Working on updating policies and procedures to meet changing regulations using the payer service.
• Data analytics and reporting. Analyzing healthcare data to identify trends and cost-saving opportunities will go through the payer tool. It can generate reports for:
  • members
  • employers
  • providers

            At the same time, it supports value-based care initiatives.

• Pharmacy Benefit Management (PBM). It handles managing the following:
  • prescription drug benefits
  • formularies
  • drug pricing

            Plus, it handles administering mail-order pharmacy services.

Healthcare payers play a critical role in facilitating access to healthcare services and managing the financial aspects of healthcare for their members.