What Is a Health Care Provider?

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A health care provider can be a doctor. Image © Siri Stafford?Getty Images

A health care provider is a person or company that provides a health care service to you. In other words, your health care provider takes care of you.

The term "health care provider" is sometimes incorrectly used to refer to a health insurance plan, but health insurance is different from health care. 

Who Are Health Care Providers?

The health care provider you’re probably the most familiar with is your PCP or primary care physician.

But, there are all different types of health care providers. Any type of health care service you might need is provided by some type of health care provider.

Here are some non-physician examples of health care providers:

  • The physical therapist that helps you to recover from your knee injury.
  • The Home Health Care Company that provides your visiting nurse.
  • The durable medical equipment company that provides your home oxygen or wheelchair.
  • Your pharmacy.
  • The laboratory that draws and processes your blood tests.
  • The imaging facility that does your mammograms, X-rays, and MRI scans.
  • The speech therapist that works with you to make sure you can swallow food safely after a stroke.
  • The outpatient surgery clinic where you had your colonoscopy done.
  • The specialty laboratory that does your DNA test.
  • The urgent care center or walk-in clinic in your neighborhood shopping center.

Why It Matters

In addition to your personal preferences about which providers you’d rather have taking care of you, your choice of providers matters for financial and insurance reasons.

 

Most health plans have provider networks. These networks are groups of providers that have agreed to provide services to the health plan’s members at a discounted rate and that have met the quality standards required by your insurer. Your health plan prefers that you use its in-network providers rather than using out-of-network providers.

In fact, HMOs and EPOs won’t pay for services you get from a health care provider that’s out-of-network except in extenuating circumstances. PPOs, and to a lesser extent POS health plans, will usually pay for care provided by out-of-network providers. However, they incentivize you to get your care from their in-network providers by charging you a higher copayment or coinsurance when you use an out-of-network provider.

If you like your doctor or other health care provider, but they’re not in-network with your health plan, you have options. During your next open enrollment, you can switch to a health plan that includes them in its network.

You can also appeal to your health plan requesting that it cover care you get from this out-of-network provider as though it was in-network care. Your health plan might be willing to do this if you’re in the middle of a complex treatment regimen being administered or managed by this provider.

Another reason your plan might allow this is if 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 quality data showing this surgeon has a significantly lower rate of post-op complications than the in-network surgeon?

Can you show that this surgeon is significantly more experienced in performing your rare and complicated procedure? If the in-network surgeon has only done the procedure you need 6 times, but your out-of-network surgeon has done it twice a week for a decade, you have a chance at convincing your insurer.

If you can convince your health plan that using this out-of-network provider might save money in the long run, you may be able to win your appeal.

Understanding the wide range of providers can help you avoid surprise balance bills

Surprise balance bills happen 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 might have knee surgery at a hospital in your health plan's network, and later find out that the durable medical equipment supplier that the hospital uses isn't contracted with your insurance plan.

So in addition to having to meet your health plan's in-network out-of-pocket maximum, you may also end up paying out-of-network charges for the knee brace and crutches, walker, or wheelchair that you end up with after the surgery.

The more you know about the range of providers involved in medical care, the better prepared you can be, at least in non-emergency situations. Some states have passed laws to limit patients' exposure to balance billing in situations where some providers at a given facility aren't part of the insurance networks with which the facility contracts.

But in general, the more questions you ask ahead of time, the better off you'll be. Inquire about the insurance network participation of any providers who might treat you—directly, or indirectly, as would be the case with durable medical equipment supplies, radiologists, and labs. Ask the hospital or clinic if there's an in-network provider option in each case, and state your desire to utilize in-network providers—keeping in mind that "provider" goes well beyond the doctor overseeing your care.

Sources:

Hoadley, Jack; Ahn, Sandy; Lucia, Kevin. Robert Wood Johnson Foundation & the Center on Health Insurance Reforms (Georgetown University Health Policy Institute). Balance Billing: How Are States Protecting Consumers from Unexpected Charges? June 2015.

National Academy for State Health Policy, Surprise Billing Legislation Passed in 2016.

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