What is a healthcare provider? (2023)

A healthcare provider is a person or organization that provides medical care or treatment. Healthcare providers include doctors, nurses, midwives, radiologists, laboratories, hospitals, emergency clinics, medical supply companies and other professionals, institutions and companies that provide such services.

The term "health care provider" is sometimes used incorrectly for a health insurance company. An insurer does not provide care services, but rather pays the person, company or person who provides them (provided the service is covered and you have met your costscost-sharing obligations).

This article explains what you need to know about healthcare providers and how their services interact with your health insurance plan.

Who are Healthcare Providers?

The healthcare provider you are probably most familiar with is your ownGeneral Practitioner (PCP)who gives youbasic servicessuch as check-ups, vaccinations and routine check-ups. There are also specialists who will see you if you need specific medical care.

There are many different types of healthcare providers. Any type of healthcare service you may need will be provided by one of them.

Not all healthcare providers are doctors. Here are some non-physician examples of healthcare providers:

• Diephysiotherapistthis will help you recover from your knee injury
• Diecare at homeCompany that provides your visiting nurse
• Diedurable medical devicesCompany that provides you with oxygen or a wheelchair at home
• Yourpharmacy
• DieLaborwhich creates and processes your blood tests
• Dieimaging facilitythat does your mammograms, X-rays, and magnetic resonance imaging (MRI) scans
• Diespeech therapist(speech therapist) who will work with you to ensure you can safely swallow food after a stroke
• DieOutpatient Surgerywhere you had your colonoscopy done
• The special laboratory for yourDNA-Test
• Dieemergency centeror walk-in clinic at your local mall
• The hospital where you receivestationary(or in some cases outpatient) care
• Dieemergency departmentPersonnel who will stabilize you in the event of an accident or serious illness
  

Why Choosing Your Healthcare Provider Matters

In addition to your personal preferences as to which providers you prefer to take care of, your choice of provider also plays a role for financial and insurance reasons.

Networks of insurance and healthcare providers

Most health plans have provider networks.These networks are groups of health care providers who have agreed to offer services at discounted rates to health plan members and who have met the quality standards required by your insurer.

Your health insurance plan prefers that you use its in-network providers instead of using out-of-network providers. Actually,Health Maintenance Organizations (HMOs)andexclusive provider organizations (EPOs)generally does not pay for services you receive from an off-network healthcare provider, except in emergency situations.

Preferred Provider Organizations (PPOs), and to a lesser extent, point-of-service (POS) healthcare plans, typically pay for care provided by off-network providers. However, they incentivize you to take your coverage from their in-network providers by imposing a higher deductible, co-payment and/or co-insurance andout of pocket at mostif you use an external provider.

If you decide to use an external provider, the provider can do sobalance invoiceYou for the part of your costs that are above thatreasonable and customary amountYour insurer is willing to pay.

Out-of-Network Healthcare Providers

If you like your current healthcare provider but it's not connected to your healthcare plan, you have options that may give you on-network access to your favorite providers.

during your nextOpen login window, you can switch to a health plan that will add you to its network. However, this might be easier said than done depending on the options available to you.

When you are enrolledInsurance coverage by an employer, your choices are limited by the options the employer offers. When you cover your own in theMarketplace for individuals/families, your choices are limited by the plan options and type of coverage offered by insurers in your area.

You can also contact your health insurance plan and request that they cover the care you receive from that off-network provider as if it were on-network care. Your healthcare plan may be willing to do this if you are in the midst of a complex treatment plan administered or administered by that healthcare provider, or if this is the only local option for delivering the treatment you need.

How to cover healthcare providers off-network as in-network

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

For example, do you have quality data showing that a particular surgeon has a significantly lower rate of postoperative complications than the surgeon in the network? Can you demonstrate that you are significantly more experienced in performing the rare and complicated procedure you require?

If the on-net surgeon has only performed the procedure you need six times, but your off-net surgeon has been doing it twice a week for a decade, you have a chance to convince your insurer. If you can convince your health insurance plan that using this outside healthcare provider could save you money in the long run, you might be able towin your appeal.

Health care providers and federal protection against surprise bills

surprisesettle billshappen in emergency situations when a patient is treated by external healthcare providers without having had a say in the matter (e.g. ).

This can also happen when a patient is treated at a facility within the network but receives some of their treatment or services from a healthcare provider outside the network.

For example you might haveknee surgeryat a hospital in your health plan's network, and later find out the durable medical equipment provider that the hospital obtained yours fromKnee bandageandcrutchesis not contracted with your insurance plan.

In the past, situations like this often resulted in the patient being confronted with bills outside the network in addition to their regular cost sharing in the network.

Lucky for consumersFederal laws went into effect in 2022, eliminating surprise balance billingin emergency situations and in situations where an off-network healthcare provider is providing services in a network facility.

ground ambulanceChanges are unaffected by this new rule (and they cause a significant number of surprise accounting bills each year), but the new rule otherwise offers solid consumer protection.

Many states had enacted laws prior to 2022 to limit patient exposure to unexpected financial statements.However, government regulations do not apply toself-insured health insurance companies, which cover the majority of people who have employer-sponsored health insurance.

The federal regulations that apply statewide to self-insured plans and fully insured plans offer broader consumer protections.

summary

Your healthcare providers are the people and organizations that take care of you when you need medical treatment. They include the entire team treating you, including specialists, facilities and support providers.

Health insurance companies are cost bearers, but not providers. Health insurance plans maintain network agreements with a variety of health care providers, and most plans will encourage or require their members to use health care providers who are in the plan's network.

VonElizabeth Davis, RN
Elizabeth Davis, RN, is a health underwriter and patient liaison. She holds board certifications in Emergency Nursing and Infusion Nursing.