Who are the top payors by provider specialty?
Payors, or insurance companies, provide financial protection and support for individuals seeking healthcare services. Healthcare providers, on the other hand, are the professionals who offer medical care to patients. Understanding the relationship between the two is critical for both individuals seeking healthcare services and providers looking to work with payors.
In the U.S., health insurance is necessary for individuals seeking healthcare services due to the high cost of medical care. The Health Insurance Marketplace was established to provide affordable health insurance options for individuals who may not be able to afford traditional healthcare plans. It offers various plans, including relatively less expensive health insurance options, which are designed for individuals on a tight budget.
No-cost health insurance options are also available for individuals who meet certain criteria. These options include Medicaid and Medicare, which are government-funded programs that provide healthcare coverage for certain people, including low-income individuals and senior citizens.
What is a claim?
A claim is a bill containing medical codes related to the specifics of treatment that healthcare providers submit to payors for payment. A claim offers insight into all of the medical services provided, including pharmaceuticals, medical devices and medical supplies.
It’s worth noting that the number of claims filed by a healthcare provider can be heavily influenced by their specialty. For example, family practice physicians and nurse practitioners often serve as the first point of contact for patients seeking medical care. They may provide a wide range of services and treatments, including preventive care, routine check-ups, and chronic disease management. Additionally, family practice physicians and nurse practitioners may see a higher volume of patients overall, which could also contribute to a higher number of claims.
Below we’ve highlighted the top three payors for the 10 largest provider specialties based on the volume of claims filed in 2022.
|Provider specialty||Top 3 payers||Percentage of claims paid for that specialty||Explore dataset|
|Family Practice||1. Blue Cross Blue Shield||35%||Explore|
|Nurse Practitioner||1. Blue Cross Blue Shield||34%||Explore|
|Physical Therapy||1. Blue Cross Blue Shield||36%||Explore|
|Diagnostic Radiology||1. Blue Cross Blue Shield||34%||Explore|
|Internal Medicine||1. Medicare||29%||Explore|
|2. Blue Cross Blue Shield||28%||Explore|
|Emergency Medicine||1. Blue Cross Blue Shield||34%||Explore|
|2. Blue Cross Blue Shield||24%||Explore|
|Pediatric Medicine||1. Blue Cross Blue Shield||49%||Explore|
|Physician Assistant||1. Blue Cross Blue Shield||34%||Explore|
|Social Work||1. Blue Cross Blue Shield||49%||Explore|
Who are the top payors?
In the data provided above Blue Cross Blue Shield (BCBS) is ranked number one in 8 of the top 10 specialties. When analyzing all of the healthcare specialties in Definitive Healthcare’s Atlas All-Payor Claims dataset, BCBS holds the number one ranking 62% of the time. This position is in line with the fact that BCBS is the top provider of health insurance services in more than half of the states in the United States.
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