What model is commonly used by payers in the healthcare industry?

In the healthcare industry, the model most commonly used by payers is the CMS policy. The Centers for Medicare & Medicaid Services (CMS) is a federal agency that governs and regulates Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). The policies established by CMS serve as a critical framework for reimbursement rules, coverage determinations, and services provided under these programs.

Payers rely on CMS policies to guide their billing practices, coding requirements, and compliance measures. These policies ensure uniformity in the way healthcare services are reported and reimbursed, thereby promoting consistency across various healthcare providers and insurers.

While other choices like Medicare Guidelines and Healthcare Frameworks play essential roles in the healthcare landscape, they do not have the same comprehensive authority and impact as the policies set forth by CMS. Insurance Standards, while important, usually focus on general practices across different types of insurance rather than the specific policies that govern federal programs.