Meaning of Healthcare Provider
A healthcare provider is a person or business that provides you with medical care. To put it another way, your healthcare practitioner looks after you. The word "healthcare provider" is frequently used interchangeably with "health insurance plan," however health insurance is not the same as health care. If the treatment is covered and you've satisfied your cost-sharing responsibilities, your health insurance plan will reimburse your healthcare provider for the services they deliver to you.
The payer is your health insurance or health plan, while the provider is the company that actually treats your medical problem.
Who Are Healthcare Providers and What Do They Do?
Your primary care physician (PCP) or the specialists you see when you require specialised medical treatment are likely the healthcare providers you're most familiar with. However, there are several sorts of healthcare professionals. A healthcare provider can give you with any form of healthcare service you require.
Here are some instances of non-physician healthcare providers:
- The physical therapist who is assisting you in your recovery from a knee injury.
- The firm that sends your visiting nurse to your house
- The firm that delivers your home oxygen or wheelchair is known as a durable medical equipment company.
- Your pharmacy
- Your blood tests are drawn and processed at a laboratory.
- Mammograms, X-rays, and magnetic resonance imaging (MRI) scans are all done at this imaging center.
- The speech therapist who works with you after a stroke to ensure that you can safely swallow meals.
- The specialist laboratory that performs your DNA test The outpatient surgical facility where you underwent your colonoscopy
- Your neighborhood shopping mall's urgent care center or walk-in clinic
- Inpatient (or, in certain situations, outpatient) treatment is provided at this hospital.
- In the event of an accident or serious sickness, the emergency department stabilizes you.
Why Does It Matter?
Your choice of providers is important for financial and insurance reasons, in addition to your personal preferences regarding which providers you'd want to have look after you. The majority of health insurance policies have provider networks. These networks are groupings of providers that have agreed to provide services to the health plan's members at a reduced charge in exchange for meeting your insurer's quality requirements. Instead of choosing out-of-network doctors, your health plan recommends that you utilize in-network providers.
In reality, except in emergency cases, health maintenance organizations (HMOs) and exclusive provider organizations (EPOs) will not pay for treatments received from an out-of-network healthcare provider. Out-of-network treatment is frequently covered by preferred provider organizations (PPOs) and, to a lesser extent, point of service (POS) health plans. When you use an out-of-network provider, however, they impose a higher deductible, copayment and/or coinsurance, and out-of-pocket maximum, incentivizing you to utilize their in-network doctors.
If you enjoy your doctor or other healthcare provider but they aren't in-network with your health plan, there are a few choices that may allow you to see them in-network:
- You can switch to a health plan that includes them in its network during your next open enrollment period.
- (Depending on the alternatives accessible to you, this may be easier said than done.)
- If you're enrolled in an employer-sponsored plan, your selections will be restricted by the alternatives offered by the company.
- If you buy insurance on your own in the individual/family market, the plan selections and types of coverage that insurers provide in your region will limit your possibilities.)
- You can also file a claim with your health insurance company, requesting that it reimburse the care you receive from this out-of-network physician as if it were in-network.
- If you're in the middle of a complicated treatment regimen delivered or supervised by this provider, or if your provider is the only local alternative for delivering the care you require, your health plan may be prepared to do so.
Another reason your plan could accept it is if you can demonstrate to them why your supplier is a better option for this service than an in-network provider. Do you have reliable statistics that this surgeon has a lower rate of post-operative problems than the in-network surgeon, for example? Can you demonstrate that this surgeon has a lot more experience conducting your unique and difficult procedure?
You have a chance of persuading your insurance if your in-network surgeon has only performed the surgery six times, but your out-of-network surgeon has performed it twice a week for a decade. You might be able to win your appeal if you can persuade your health plan that choosing an out-of-network provider would save you money in the long term.
How to Stay Away From Surprising Balance Bills and Federal Relief?
Surprise balance bills occur when a patient is treated by out-of-network providers without their knowledge (e.g., they were transported by ambulance to the nearest emergency department, which was not in-network with their insurance plan), or when a patient is being treated at an in-network facility but receives treatment or services from an out-of-network provider. For example, you could have knee surgery at a hospital in your health plan's network only to discover later that the durable medical equipment provider that the hospital chose to provide your brace and crutches isn't covered by your plan. So, in addition to meeting your health plan's in-network out-of-pocket limit, you could have to pay out-of-network rates for the knee brace, crutches, walker, or wheelchair you need following surgery.
The more you understand about the various medical providers, the more prepared you will be, at least in non-emergency scenarios. In circumstances when certain physicians at a given facility aren't part of the insurance networks with which the facility contracts, an increasing number of states have implemented regulations to limit patients' vulnerability to balance billing.
In addition, in 2022, federal regulations will go into effect that will ban surprise balance charging in emergency cases and when an out-of-network provider conducts treatments at an in-network institution. This new law will not affect ground ambulance changes (which account for a considerable number of unexpected balance bills each year), but it will give excellent consumer protection in other ways.
In 2018, federal laws went into effect that give some protection to patients who are subjected to unexpected balance billing when they purchase health plans through the health insurance marketplaces. Unless the insurer provided adequate notice to the patient that they would be facing out-of-network charges, exchange plans are required to apply out-of-network charges from ancillary providers (i.e., providers who are supplemental to the primary provider who is performing the procedure) towards the patient's in-network cap on out-of-pocket costs. However, the patient is still accountable for out-of-network expenses, which are not subject to any kind of restriction under the laws. Fortunately, the new laws, which go into force in 2022, are significantly more solid in terms of safeguarding consumers against unexpected balance charging.
Some states have previously taken steps to address the issue on their own, but unexpected balance bills are still widespread in many others. Self-insured group plans are also governed by federal rather than state regulations. The vast majority of persons with employer-sponsored coverage are enrolled in self-insured plans, which are exempt from state requirements. This is why federal action was required, and why the laws that will go into effect in 2022 will offer far more protection than anything the states could have done on their own.
The more questions you ask ahead of time, regardless of the regulations in place, the better off you'll be. Inquire about any providers who may treat you—directly or indirectly, as with durable medical equipment supply, radiologists, and labs—and their insurance network involvement. In each scenario, ask the hospital or clinic if an in-network provider is available, and express your preference to use in-network providers—keep in mind that "provider" refers to more than just the healthcare physician overseeing your treatment.