What is a health care provider?

A health care provider is a natural or legal person who provides you with health care services. In other words, your healthcare provider will take care of you.

The term health care provider is sometimes used incorrectly to refer to a health plan, but health insurance is different from health care. Your health plan will pay your healthcare provider for the services they provide to you, as long as the service is covered and you meet your cost-sharing responsibilities .

The insurance company or health plan is the payer and the provider is the person who actually treats your condition.

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Who are the healthcare providers?

The healthcare provider you are probably most familiar with is your primary care physician (PCP) or the specialists you see when you need certain medical care. But there are different types of health care providers. Certain types of health professionals provide all the health care services you may need.

Here are some examples of health care providers who are not doctors:

  • A physical therapist to help you recover from a knee injury.
  • A home care company that provides a nurse
  • A durable medical device company that provides oxygen or a wheelchair to your home.
  • Your pharmacy
  • The laboratory that takes and processes your blood tests.
  • An imaging center that performs mammograms, x-rays, and magnetic resonance imaging (MRI).
  • A speech therapist who will work with you to make sure you can safely swallow food after a stroke.
  • The outpatient surgery clinic where you had your colonoscopy.
  • A specialized laboratory that performs your DNA test
  • Emergency center or clinic in the shopping center next door.
  • The hospital where you receive inpatient (or, in some cases, outpatient) care.
  • An emergency department that stabilizes you in the event of an accident or serious illness.

Because it is important

In addition to your personal preferences as to which providers you prefer to see, your choice of providers is important for financial and insurance reasons.

Most health plans have provider networks . These networks are groups of providers who have agreed to provide services to members of a health plan at a reduced rate and who meet the quality standards required by their insurer. Your health plan prefers that you use in-network providers rather than out-of-network providers.

In fact, Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs) will generally not pay for services you receive from an out-of-network healthcare provider, except in emergencies.

Preferred Provider Organizations (PPOs) and, to a lesser extent, Point of Service (POS) plans generally pay for services provided by out-of-network providers. However, they encourage you to obtain medical care from your in-network providers by charging higher deductibles, copayments and / or coinsurance, and maximum out-of-pocket allowances when you use an out-of-network provider.

If you like your doctor or other health care provider, but they are not in your health plan's network, you have options that can give you in-network access to your preferred providers:

The next time you open the enrollment window, you can switch to a health plan that includes them in their network. (This may be easier said than done, depending on the options available to you. If you participate in employer-provided coverage, your options will be limited to the options that the employer provides. If you purchase your own coverage in the individual market / family , your options will be limited by plan options and the type of coverage provided by insurers in your area.)

You can also file an appeal with your health plan to cover the services you receive from that out-of-network provider as if they were in-network services. Your health plan may be willing to do this if you are in the middle of a complex treatment regimen that is administered or administered by that provider, or if your provider is the only local option to provide the treatment you need.

Another reason your plan might allow this is so you can show the plan why your provider is a better choice for this service than an in-network provider.

For example, do you have qualitative data showing that this surgeon has a significantly lower postoperative complication rate than a network surgeon? Can you show that this surgeon has much more experience with your rare and complex procedure?

If your in-network surgeon has done the procedure you want six times and your out-of-network surgeon has done it twice a week for ten years, you have a chance to convince your insurer. If you can convince your health plan that using this out-of-network provider can save you money in the long run, you can win your appeal.

Avoid unexpected bills (and federal aid planned for 2022)

Unexpected balances occur in emergencies when a patient is being treated by an out-of-network provider but has no say in the matter (for example, they were taken by ambulance to the nearest emergency room that was not connected to their network). ) or when a patient receives treatment at a network facility, but receives treatment or services from an out-of-network provider.

For example, you may have knee surgery at a hospital in your health plan's network and then discover that the supplier of durable medical equipment that the hospital used to supply your braces and crutches is not contracted with your insurance plan.

So, in addition to making sure you have as much cash as possible within your health plan's network, you may also end up paying out-of-network payments for knee braces and crutches, walkers, or wheelchairs that you will have after surgery. .

The more you know about the provider circle, the better prepared you can be, at least in non-emergency situations. An increasing number of states are enacting laws restricting the ability of patients to be billed for services in situations where some of the providers at a particular institution are not part of the network with which the institution participates.

And in 2022, federal rules will go into effect that eliminate unexpected billing in emergencies and in situations where an out-of-network provider provides services at an in-network facility. This new rule will not affect changes to the ground ambulance system (and they account for a significant number of unexpected balance accounts each year), but otherwise, the new rule provides strong consumer protection.

2018 also put into effect federal rules applicable to health insurance plans purchased on health insurance exchanges , which provide some protection when patients are exposed to unexpected bills.

Exchange plans must apply out-of-network payments for ancillary providers (that is, providers that are in addition to the primary provider performing the procedure) against the patient's network out-of-pocket limit, unless the insurer has given the patient appropriate notice to inform the patient that they will be charged offline.

But the patient is still responsible for paying out-of-network payments and the regulations do not require any restrictions on these costs. Fortunately, the new rules, which go into effect in 2022, are much stronger in terms of protecting consumers from unexpected bills.

Some states have already solved this problem on their own, but unexpected balances are still common in many states. And group self- insured plans are governed by federal, not state, rules. Most people with employer-sponsored coverage are enrolled in self-insurance plans. and government regulations do not apply to these plans. That's why action was required at the federal level and why the regulations that go into effect in 2022 will provide far more protection than anything governments have done on their own.

But no matter what the rules are, the more questions you ask ahead of time, the better. Find out about any provider that can treat you directly or indirectly, such as durable medical equipment, radiologists and laboratories, to be part of the insurance network.

Ask the hospital or clinic if there is an in-network provider option in each case, and express your desire to use in-network providers, remembering that the 'provider' goes well beyond the provider who oversees your care.

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