Phone: (606)549-4811 * Fax: (606) 549-4814 * E-mail: * 410 Sycamore Street, Williamsburg, KY 40769

Tuesday, October 7, 2014

Obamacare: Have you heard that health insurance is changing? (Part Three - Participating Providers)

Dr. Matt, does it matter if a patient's doctor participates with the patient's health insurance plan? 

Yes.  It absolutely does. 

Just because a doctor advertises or tells someone that he "takes insurance" or "accepts insurance" does not necessarily mean that patients will get the perks of seeing a "participating provider" if they go there. 

Also, just because a doctor is participating with one plan that an insurance carrier has does not necessarily mean that the participate with all of the plans offered by that insurer. 

Therefore, taking a few minutes to understand a few important concepts that are addressed in this blog could save some patients a lot of money down the road.

Today I want to define a few terms first, and then we will look at the advantages and disadvantages of using a participating provider versus a non-participating provider.  The details of this topic may vary slightly from one insurance plan to another, but the basic concepts generally hold true for most insurers.

Participating providers:  These providers have signed a contract with an insurance carrier.  In exchange for being listed in provider directories and being offered direct access to more patients participating providers must accept a lower fee for their services.  There may also be other requirements that the provider must meet.  Participating providers are sometimes called "par" providers or "in-network providers". 

Non-participating providers:   These providers have the same training and the same license as participating providers, so there is not necessarily a difference in the care they provide to their patients.  However, non-participating providers generally have not entered into any kind of contract with an insurer and they are not bound to the insurance company's fee schedule.  There are many reasons that providers may not participate, but it is often because they think that the fee that they must accept from the insurer is too low and they are not willing to accept that as payment in full. Non-participating providers are sometimes called non-par or out-of-network providers.

Balance Billing:  This term is often used to describe the practice of billing a patient for the difference between the provider's fee schedule and the amount that the insurance carrier allows the provider to charge  Participating providers are usually not allowed to balance bill patients or charge more than the amount allowed by insurance carrier no matter what their normal fee is.  For example, a chiropractor may charge $35 for an adjustment but the insurer only allows a $23 charge; in that situation a participating provider must accept the $23 payment as payment in full and he cannot bill the patient for the remaining $12.   

Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs):  In most situations, these kinds of plans only cover care that you receive from participating providers who are "in network" with them.  There are other differences related to the requirements for referrals to specialists or  forcing patients to have a primary care provider.  However, those details are not extremely relevant to this discussion.

Preferred Provider Organizations (PPOs) and Point-of-Service plans (POS):  These plans will allow patients to see a non-participating, out-of-network provider.  However, since non-participating providers may charge a higher fee, the insurer usually makes the patient pay a larger percentage of the bill.

In the real world what is the advantage to seeing a participating provider versus a non-participating provider?

In the real world, it all comes down to how much the care may cost the patient. 

For one thing, if the provider is non-participating with an HMO the insurance carrier may not cover that provider's care at all in some situations

If the carrier is a PPO, there are some huge differences between participating and non-participating providers.  First, the patient's agreement with the insurance carrier often states that the patient must pay a higher percentage of the provider's charges.  Second, the provider is not bound to a fee schedule and there are no limits on how much the doctor can charge the patient.  Lastly, if the patient sees an out-of-network specialist there may be additional referral requirements in order to get the insurance to cover a specialist visit.

How is this relevant to Obamacare?

In a recent blog I addressed how under the new health care laws many insurance plans are moving from a "copay" system to a deductible/coinsurance system in which patients pay more out of pocket.  Even if the insurance never pays a dime for the care, one advantage to seeing a participating provider is that participating providers must accept a lower fee for the same service.  With many of these new, high-deductible Obamacare plans, the fact that a participating provider must accept a lower fee can save patients a lot of money.

As is the case with our previous blogs in this series, this information is nothing new and most of these ideas have been around for some time.  However, with the current changes that are taking place in insurance we have been getting a lot of questions from patients about their new insurance plans, so we decided to do this blog series to address these common questions.

How do I know if my doctor participates with my insurance plan?

You can always ask the provider, but don't ask if they "accept" your insurance.  Instead, ask them if they are a participating provider or if they are "in-network" with your insurance company. 

An even better way to find out is to go to the insurance carrier's website and do a search for participating providers in your area.  Some insurers also publish provider directories or have phone numbers that you can call to see if a provider is in network.

Is Christopher Chiropractic "in-network" with any insurance carriers?

We recognize that we practice in a rural area where access to care is limited to begin with.  Therefore, we strive to be "in-network" with all carriers so that quality chiropractic care is available and affordable to anyone who wishes to see us.  We do not want patients to miss out on chiropractic just because we do not participate with their insurance plan.  This is also consistent with our conscious effort to get patients well in a way that requires them to spend as little time, money and energy as possible in our office.

We are participating providers with Medicare and Kentucky Medicaid, Wellcare, Conventry Cares. We are also in-network with Anthem Blue Cross Blue Shield, Humana, Bluegrass Family Health, United Healthcare, UMR, Aetna, Cigna, the University of the Cumberlands student plans, and so many other insurance companies that I can't even list them all.  Additionally, we are in the process of becoming in-network providers with other insurers and Kentucky Medicaid managed care organizations who will soon be operating in Kentucky. 

I would encourage a prospective patient to check with their insurer or call our office at 549-4811 to see if we participate in their plan. 

If they want to talk with me about our participation with a specific insurance carrier, I would love to talk with them.  Even if I'm with patients folks can leave a message and I'll return the call within a few hours.  Dr. Liz, Jodi or most of our other team members can also answer basic questions about many of the insurance plans that we work with.

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