How Do Healthcare Providers Works?

A health plan or health insurance provider may occasionally be mistakenly referred to as a “healthcare provider”. However, care is not provided by an insurer or health plan administrator. Instead, if the service is covered by the plan and you’ve complied with your referral, prior authorization, and cost-sharing obligations, that entity pays the person or other business that performs the treatment.

What you should know about healthcare providers and how their services work with your health insurance plan is covered in this article.

Health Care Providers: Who Are They?

Your primary care physician (PCP), who provides you with primary care services like screenings, immunizations, and routine exams, is the healthcare professional you’re most likely most familiar with. When you require specialized medical care, you can also see a specialist.

health service providers come in a wide variety of forms. One of them offers any kind of medical service you might require.

Not all healthcare professionals are doctors or physicians.

Here are a few instances of healthcare practitioners that are not doctors:

  • The physical therapist who aids in your knee injury recovery
  • Your visiting nurse’s home healthcare provider (the nurse is a healthcare professional);
  • The business that sells durable medical equipment and delivers your wheelchair or home oxygen supply
  • Your drugstore
  • The facility that collects and analyzes your blood samples
  • The imaging facility where you have your X-rays, MRIs, and mammograms performed
  • The speech therapist or speech pathologist who works with you to ensure that you can properly swallow food after a stroke
  • The outpatient surgical facility where you underwent a colonoscopy
  • The specialized lab that does your DNA test
  • The walk-in clinic or urgent care facility in the neighborhood mall
  • The medical facility where you receive inpatient (or occasionally outpatient) care
  • The emergency hospital transportation service, whether by air or ground
  • The medical professionals at the emergency room who keep you comfortable in the event of an accident or serious illness
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Why It’s Vital to Choose a Healthcare Earner

Healthcare

Your choice of providers matters for financial and insurance reasons in addition to your personal preferences regarding which professionals you would choose to take care of you.

Healthcare and Insurance Provider Networks

Provider networks are a feature of almost all health plans2 (this includes Medicare Advantage plans, commercial individual and group health plans, and the majority of Medicaid subscribers’ coverage3). In contrast to managed care plans with provider networks, indemnity plans made up just 1% of employer-sponsored health plans as of 2022.4

These networks are collections of medical professionals who have consented to offer reduced care to the health plan’s subscribers in exchange for meeting the quality criteria set out by your insurer.

Healthcare

Instead of choosing out-of-network physicians, your health plan would prefer that you use its in-network doctors. In fact, unless there is an emergency, health maintenance organizations (HMOs) and exclusive provider organizations (EPOs) won’t often pay for services you receive from a healthcare provider who is not in their network.

Additionally, if you decide to use an out-of-network provider, they may balance charge you for the fraction of their expenses that exceeds what your insurance would cover as a fair and customary amount. (As explained below, in circumstances where you practically have no choice in the supplier you use, this is no longer permitted. This covers both unplanned visits and non-network treatment received at a facility that accepts your insurance.)

Providers of Healthcare Outside of Network

There are solutions available to you if your preferred healthcare provider is not part of the network covered by your health plan but you like them.

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You have the option of switching to a health plan that has them in its network during your subsequent open enrollment period. But depending on your options, this can be easier said than done.

Healthcare

The choices available to you if you’re enrolled in coverage offered by your employer will be constrained. Your options will be constrained if you purchase your own insurance in the individual/family market by the types of plans and coverage that the insurers in your area offer.

How to Cover Healthcare Providers Who Are Not in the Network as In-Network

If you can convince the plan that your healthcare provider is a superior option for this service compared to an in-network healthcare provider, your plan might also permit this.

Do you, for instance, have reliable statistics demonstrating that a specific surgeon considerably has a lower rate of post-operative problems than the in-network surgeon? Can you provide evidence that they have much more expertise executing the challenging and uncommon surgery you require?

You may be able to persuade your insurer if your out-of-network surgeon has performed the surgery twice a week for ten years whereas the in-network surgeon has only performed it six times. Your health plan may agree to your appeal if you can persuade them that going with this out-of-network doctor will ultimately cost less money.

Federal Protections Against Surprise Balance Bills for Healthcare Providers

When a patient is treated by healthcare professionals who are not in their insurance plan’s network without their consent in an emergency, surprise balance bills might result (for example, if they were taken by ambulance to the closest emergency department, which was not in their insurance plan’s network).

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This can also occur when a patient receives some of their care at an in-network institution and some of it from an out-of-network healthcare provider.

For instance, you might undergo knee surgery at a hospital inside the network of your health plan and subsequently learn that the company from which the hospital obtained your knee brace and crutches does not have a contract with your insurance company.

In the past, situations like this would force the patient to pay both their usual in-network cost-sharing as well as any out-of-network charges.

Fortunately for consumers, federal regulations that went into effect in 2022 eliminated surprise balance billing in emergency cases and when a healthcare practitioner from outside the network provides services.

Ground ambulance adjustments are not covered by this new rule, despite the fact that they frequently result in unexpected balance bills. Nevertheless, the new rule offers good consumer protection overall.

Summary

When you require medical care, your healthcare providers are the people or organizations that look after you. They include all members of the treatment team, including specialists, locations, and support services.

Plans for health insurance are payers but not providers. Health insurance plans have network agreements with a variety of healthcare organizations, and the majority of plans encourage or mandate that their members use organizations that are part of the network.

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