Payer

An insurance company, health plan, or government program (such as Medicare or Medicaid) that reimburses healthcare providers for medical services rendered to covered members or beneficiaries.

A payer is any organization that pays for healthcare services. In credentialing, when we say "payer" we typically mean health insurance companies, government programs, and managed care organizations. Payers fall into several categories. Commercial payers are private insurance companies like Aetna, Cigna, UnitedHealthcare, Blue Cross Blue Shield, and Humana. Government payers include Medicare (administered by CMS), Medicaid (administered by each state), TRICARE (for military families), and CHAMPVA (for veterans' dependents). Managed care organizations like Molina, Centene, and Amerigroup operate Medicaid managed care plans on behalf of state governments. Each payer has its own credentialing process, its own timeline, its own forms, and its own quirks. Some accept CAQH ProView, some do not. Some process applications in 30 days, some take 150 days. Some backdate your effective date to the application submission date, some do not. The number of payers you need to enroll with depends on your practice setting and patient population. A typical primary care physician in a mid-sized market might need to be credentialed with 10 to 20 different payers to cover the majority of their patient panel. A specialist in a niche field might only need five to eight. When deciding which payers to enroll with, look at the payer mix in your geographic area. Talk to other providers in your market. Find out which plans the local employers offer. Check which Medicaid managed care plans operate in your state. Prioritize the payers that cover the largest share of potential patients, and do not forget Medicare, which covers virtually every patient over 65.