Payor Mapping, Where's the Master?
Updated: Feb 25, 2022
I have been looking and I cannot find one. A master list of all healthcare insurance carriers and their categorization into core payor classes. During my search I built my own, and of course I have general standard categories, but I also have client-specific and state-specific categories. Through this regular process of additions and updates of my master payor mapping, I have come up with tips around building your own, and theories why there likely will never been a true master payor mapping across all insurance carriers.
TIP ONE: Developing Core Payor Categories
I personally like tiering in my payor mappings. For my table I use 4 levels.
Level 1: Core categories of Government, Commercial, Self Pay, Charity, Interest, Exclude/Remove
Level 2: Splitting of Government payors into categories of Medicare, Medicaid, Tricare/Champus/VA.
Level 3: Splitting out of core Commercial payors to BUCAH* vs general Commercial, and then splitting of Medicare into Traditional vs Managed, splitting of Medicaid into State and Out of State. Finally, pulling out any client-specific special payor categories.
Level 4: At this final level we can split out the BUCAHs into the three sub-plans of Managed Medicare, Managed Medicaid, and general Commercial. Splitting out Supplemental plans might be good for your organization if you have to track payor reimbursement shifts. Splitting out any Workers Comp and Auto.
You will most often use something like a payor mapping level 3 for financial reporting and/or inventory analysis. However, the other categories greatly help sort and roll up or down the data for any needs.
Quick side tangent. This term, "*BUCAH". You may have seen it also as "BUCA", I added the "H" at the end because it just makes sense. These are the national payors that rule the markets outside of Medicare and Medicaid. They are major plan administrators and you will always have two or three that make up the largest percentage of your payor mix outside of core government payors.
B - Blue Cross Blue Shield (BCBS)
U - United Healthcare (UHC)
C - Cigna
A - Aetna
H - Humana
TIP TWO: Obtaining Payors to Map
Start internally with your own data sets. Pull every payor category column from your database: Primary Carriers, Secondary Carriers, Current Carrier, Parent Insurance, etc. Next pull from any clearing house you can find a payor list (examples: Availity, Change Healthcare, Waystar, etc). Finally, and especially important if your service line is external to the facility (example: ProFee billing), get a master mapping from any facility where you receive data.
Make sure you get with your financial/analytics teams to look at reimbursement trends if a payor looks mixed or if there is something the team tracks separately, such as a special payor category. If you want the mapping to be useful, you have to make it work for everyone in a way they can easily understand.
TIP THREE: Start Manually Mapping
It is very tedious the first time. Some of these tables will help, but there are numerous internet searches and remapping that will have to take place to get it right. Make sure you do not remove any variations on spelling, punctuation, or spacing. These errors come over in facility feeds due to human error in the registration space, they will always come over so it is best to just keep mapping them.
There will be times you need to remap a set of payor lines, these categories I have were not determined on first pass. They grew and changed as our market and clients grew and changed. Today most payors we map are general commercial plans. But we still map every month at minimum. My master now has more than 37 mapping categories across the four levels, with around 18,000 payor lines.
Why Create Your Own Mapping?
Here is a secret, no one has it right. In the healthcare insurance world, each billing entity, revenue cycle vendor, payor clearinghouse and facility have their own special sauce for mapping. On top of that, each year "mom and pop" payors, auto and workers comp, and new plans flood the market requiring a new set of mappings. I would like to think that somewhere out there is a beautiful registry that has every insurance (healthcare or otherwise), but I have yet to find one. So, happy hunting, or in the meantime, happy mapping. I hope this info is helpful or insightful and allows you to build some structure into your data and reporting.