Healthcare-Payers

A Payer is an organization that has contracted with patient to pay for a patients health care services- Usually an insurance company.

Payors may be either government agencies or private companies.

In some cases the patient itself is the payer in-case the patient is not insured with a third party administrator/payer, and the patient must pay out-of-pocket in full for all services rendered, as with any other service industry.

These insurance companies/payors are mostly funded by the members’ premium. Payer will pay only if it is medically necessary. Payer organizations worldwide are focused on managing the gap between funding and medical costs, often in the context of a changing regulatory environment.

The corporate leaders of health care intermediaries are facing numerous challenges. Effective solutions to these challenges need to be tailored to local health-care systems, and payer organizations must find the best ways to influence the evolution of their health care systems.

The purpose of health care system is “to provide preventive/primary care and adequate access to quality care at a reasonable price to everyone”.

Initially, providers provided medical service to patients and in return for “payment” for their services. This was the basic “fee for services” model and there was no standard fee specified.

Healthcare is currently experiencing a critical shift: away from the current “the more a provider does, the more he/she gets paid” fee-for-service model to a robust, integrated model focusing on coordination of care known as outcome based care.

Q.1 a. Description of primary data assets that are produced by healthcare payers

* In recent years, several states have established databases that collect health insurance claims information from all health care payers into a statewide information repository.

* Known as “all-payer claims databases” or “all-payer, all claims databases,” they are designed to inform cost containment and quality...