Private payer coverage and payment - Reimbursement

Private payers make decisions daily about whether they will cover and pay for medical services. Each payer makes its own decisions based on it own criteria and patient population. Thus, coverage varies widely. Payment decisions are made through contracts with individual providers or provider networks, including accountable care organizations. Payment rates too vary widely among payers.

Coverage Policies
Coverage Policies

Coverage Policies

Private payer coverage policies are critically important in the use of medical services. Through them, payers define what they will pay for and the specific conditions, indications, and circumstances that are necessary for payment. Their coverage policies also often make clear what they will not pay for.

Coverage policies change over time, particularly as new evidence becomes available and as new medical technologies are developed. Sometimes these adjustments reverse previous policies; sometimes they merely footnote new studies or other information.

This page highlights key coverage policies, but it is important to understand that they are just highlights. Payers maintain thousands of policies.

Company: Aetna

Policy: Magnetic Resonance Spectroscopy (MRS)

Date: April 2017

Company: Aetna

Policy: CT Colonography

Date: March 2017

Company: Aetna

Policy: Cardiac CT, Coronary CT Angiography, and Calcium Scoring

Date: January 2017

Company: Blue Shield of California

Policy: Coronary CTA

Date: February 2017

Company: Blue Cross Blue Shield of Illinois

Policy: Digital Breast Tomosynthesis

Date: August 2015

Company: Blue Cross Blue Shield of Illinois

Policy: CT Colonography

Date: January 2016

Company: Health Care Services Corporation (HCSC)

Policy: Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer

Date: January 2016

Company: Health Care Services Corporation (HCSC)

Policy: Radiofrequency Ablation (RFA) of Primary or Metastatic Liver Tumors

Date: May 2016

Company: Humana

Policy: CT Colonography

Date: February 2017

Company: United Healthcare

Policy: Digital Breast Tomosynthesis

Date: April 2017
Technology Assessment
Technology Assessment

Technology Assessment

Private payers use a variety of technology assessment organizations to review the clinical and economic benefits of medical services and technology. This includes their own internal assessment organizations, such as the Blue Cross Blue Shield Association’s Technology Evaluation Center, and government agencies that do reviews, such as the Agency for Healthcare Research and Quality. In addition, a wide range of private companies offer technology evaluation services to payers. The following highlights several key technology assessment organizations.

Agency for Healthcare Research and Quality

California Technology Assessment Forum (CTAF)

ECRI Institute

Institute for Clinical and Economic Review (ICER)

International Network of Agencies for Health Technology Assessment (INAHTA)

International Society for Pharmacoeconomics and Outcomes Research (ISPOR)
Private Payers
Private Payers

Private Payers

More than 125 health insurance companies provide private health coverage in the US, though the top 25, ranked by market share, collect about two-thirds of the premiums. The following are some of the key private payers and commercial insurers.

Aetna

Anthem/Wellpoint

Blue Cross of California

Blue Cross Blue Shield of Illinois

Blue Cross Blue Shield of Massachusetts

Blue Cross and Blue Shield of Oklahoma

Blue Cross and Blue Shield of Tennessee

Cigna

Fallon Community Health Plan

GHI/Emblem Health

Harvard Pilgrim Health Care

Healthnet

Humana

Horizon Blue Cross and Blue Shield of New Jersey

Premera Blue Cross

Tufts Health Plan

United Healthcare

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Private payer coverage
and payment

Coverage Policies

Technology Assessment

Private Payers

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Health reform among private payers

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