BackgroundInsurance status may influence quality of opioid analgesic (OA) prescribing among patients seen by the same clinician.ObjectiveTo explore how high-risk OA prescribing varies by payer type among patients seeing the same prescriber and identify clinician characteristics associated with variable prescribingDesignRetrospective cohort study using the 2016–2018 IQVIA Real World Data – Longitudinal PrescriptionParticipantsNew OA treatment episodes for individuals ≥ 12 years, categorized by payer and prescriber. We created three dyads: prescribers with ≥ 10 commercial insurance episodes and ≥ 10 Medicaid episodes; ≥ 10 commercial insurance episodes and ≥ 10 self-pay episodes; and ≥ 10 Medicaid episodes and ≥ 10 self-pay episodes.Main Outcome(s) and Measure(s)Rates of high-risk episodes (initial opioid episodes with > 7-days’ supply or prescriptions with a morphine milliequivalent daily dose >90) and odds of being an unbalanced prescriber (prescribers with significantly higher percentage of high-risk episodes paid by one payer vs. the other payer)Key ResultsThere were 88,352 prescribers in the Medicaid/self-pay dyad, 172,392 in the Medicaid/commercial dyad, and 122,748 in the self-pay/commercial dyad. In the Medicaid/self-pay and the commercial-self-pay dyads, self-pay episodes had higher high-risk episode rates than Medicaid (16.1% and 18.4%) or commercial (22.7% vs. 22.4%). In the Medicaid/commercial dyad, Medicaid had higher high-risk episode rates (21.1% vs. 20.4%). The proportion of unbalanced prescribers was 11–12% across dyads. In adjusted analyses, surgeons and pain specialists were more likely to be unbalanced prescribers than adult primary care physicians (PCPs) in the Medicaid/self-paydyad (aOR 1.2, 95% CI 1.16–1.34 and aOR 1.2, 95% CI 1.03–1.34). For Medicaid/commercial and self-pay/commercial dyads, surgeons had lower odds of being unbalanced compared to PCPs (aOR 0.6, 95% CI 0.57–0.66 and aOR 0.6, 95% CI 0.61–0.68).ConclusionsClinicians prescribe high-risk OAs differently based on insurance type. The relationship between insurance and opioid prescribing quality goes beyond where patients receive care.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-023-08025-6.