Understanding the Difference Between Healthcare Payers and Providers

May 21, 2023

As the healthcare industry enters into a new era post the pandemic, people are finding it tough to keep up with the rapid change in the healthcare system. Right from staying informed on all of the industry-specific jargon, codes, and business names to the constant changes in government regulations, it is a lot for even the most experienced industry insiders to keep up with.

Healthcare Payers and Providers – Who are They?

Who is a Healthcare Provider?

A healthcare provider is a person or company that provides a healthcare service for you. Often mistaken for a service plan, a healthcare provider can be a hospital or clinic you go to or a doctor you consult.

Healthcare providers can be broadly classified into institutions, individual practitioners, and ancillary providers.

  • Institutions: These are organizations such as hospitals, nursing homes, home health agencies, and ambulatory surgery centers.
  • Individual practitioners: doctors, physician assistants, nurse practitioners, and therapists come under this category.
  • Ancillary providers: These include durable medical equipment (Defibrillators, patient monitors, surgical tables, EKGs, anesthesia machines), x-rays, clinical laboratories, and outpatient services.

Who is a Healthcare Payer?

Healthcare payers are responsible for setting service rates, collecting payments, processing claims, and paying provider claims. Without payers, providers would not be reimbursed for their services, and patients would be responsible for the full cost of their care.

There are a variety of payers in the healthcare system, including health plan providers, Medicare, Medicaid, and Veterans Affairs. Each payer has its own rules and regulations regarding coverage, reimbursement, and provider contracts.

Payers also have different relationships with providers. Some healthcare payers are directly contracted with providers, while others simply reimburse providers for the services rendered.

The role of healthcare payers and providers can be interlinked since the former is responsible for ensuring that the latter is compensated for their services and that patients are given access to affordable healthcare.

Why Understanding the Difference Between Healthcare Payers and Providers is Important?

The difference between healthcare payers and providers is essential to understand how the healthcare system works since it is a complex mix of public and private entities working together to provide patient care.

By understanding the difference between payers & providers and how they interact, we can develop a bridge of understanding between the customers and healthcare providers. Improved BPO services such as streamlining medical bill collections or creating a patient profile for better interaction can increase the confidence and trust in providers. This also functions as a means to build a good and strong relationship between the two.

First Credit Services strives to make the payment process between payers, patients, and providers as seamless as possible by offering effective medical accounts receivable management services. We utilize state-of-the-art technology like our proprietary OmniXp platform, combined with our highly trained medical collections staff to ensure higher reimbursement rates and shorter AR days.

Get to know more about First Credit Services and how we can help you optimize your revenue cycle process by visiting us online or giving us a call today.

Also Read: Why should cybersecurity in healthcare be a top priority?

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