A healthcare provider is a person or entity that provides medical care or treatment. Healthcare providers include doctors, nurse practitioners, midwives, radiologists, labs, hospitals, urgent care clinics, medical supply companies, and other professionals, facilities, and businesses that provide such services.
This article explains what you need to know about healthcare providers and how their services interact with your health insurance plan.
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Who Are Healthcare Providers?
The healthcare provider you’re probably the most familiar with is yourprimary care physician (PCP), who gives you primary care services like screenings, vaccinations, and routine exams. There are also specialists that you see when you need certain specific medical care.
Not all healthcare providers are physicians or doctors. Here are some non-physician examples of healthcare providers:
How to Find a Healthcare Provider
There are many places that you can turn to if you need a healthcare provider—whether forprimary careor specialist services.
Why Your Healthcare Provider Choices Matter
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.
Insurance and Healthcare Provider Networks
Nearly all health plans have provider networks (this includes private individual and group health plans,Medicare Advantageplans, and the majority of the coverage that Medicaid enrollees receive). As of 2023, only 1% of employer-sponsored health plans were indemnity plans (which pay a portion of your medical bills but do not replace major medical insurance), as opposed to managed care plans with provider networks.
Your health plan prefers that you use itsin-network providersrather than using out-of-network providers. In fact,health maintenance organizations (HMOs)andexclusive provider organizations (EPOs)generally won’t pay for services you get from a healthcare provider that’s out-of-network except in emergency situations.
TheAffordable Care Act’s cap on out-of-pocket costsis only applicable for in-network care, so health plans can allow much higher out-of-pocket limits (or no limit at all) on out-of-network care, even if they offer coverage for it.
If you choose to use anout-of-network provider, the provider canbalance billyou for the portion of their costs that are above thereasonable and customary amountyour insurer is willing to pay.(However, as described below, this isno longer allowedfor situations in which you essentially have no choice in the provider you use. This includes emergencies as well as out-of-network care received at an in-network medical facility.)
Out-of-Network Healthcare Providers
If you like your current healthcare provider but they’re not in-network with your health plan, you have options that may give you in-network access to your preferred providers.
During your nextopen enrollment window, you can switch to a health plan that includes them in its network. But this may be easier said than done, depending on the options available to you.
How to Get Out-of-Network Healthcare Providers Covered 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 this service than an in-network healthcare provider.
For example, do you have quality data showing a particular surgeon has a significantly lower rate of post-op complications than the in-network surgeon? Can you show they are significantly more experienced in performing the rare and complicated procedure you need?
If the in-network surgeon has only done the procedure you need six times, but your out-of-network surgeon has done it twice a week for a decade, you have a chance ofconvincing your insurer. If you can convince your health plan that using this out-of-network healthcare provider might save money in the long run, you may be able towin your appeal.
Healthcare Providers and Federal Protections Against Surprise Balance Bills
This can also happen when a patient is being treated at an in-network facility but receives some of their treatment or services from an out-of-network healthcare 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 used to source yourknee braceandcrutchesisn’t contracted with your insurance plan.
Situations like this often used to result in the patient being stuck with out-of-network bills in addition to having to pay their regular in-network cost-sharing.
Fortunately for consumers,federal rules took effect in 2022 eliminating surprise balance billingin emergency situations and in situations where an out-of-network healthcare provider performs services at an in-network facility.
Numerous states had already passed laws to limit patients' exposure to surprise balance billing prior to 2022.However, state regulations don’t apply toself-insured health plans, which cover the majority of people who have employer-sponsored health coverage.
The federal regulations, which apply nationwide to self-insured plans and fully-insured plans, provide more substantial consumer protections.
Summary
Your healthcare providers are the people and entities who care for you when you need medical treatment. They encompass the entire team that treats you, including specialists, facilities, and ancillary providers.
Health insurance plans are payers, but they are not providers. Health insurance plans maintain network agreements with a wide range of healthcare providers, and most plans will encourage or require their members to use healthcare providers who are in the plan’s network.
While your healthcare providers are obviously important when you’re in need of medical care, it’s also important to understand the relationship that specific healthcare providers have with your health plan (or any health plan you’re considering). You don’t want to inadvertently use an out-of-network healthcare provider, as you may find that you owe a lot more for the care than you expected.
It’s a good idea to always check with both the health plan and the provider to ensure that they’re in-network before scheduling or receiving any non-emergency medical care.
12 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Cornell Legal Information Institute.29 CFR § 825.125 - Definition of Health Care Provider.KFF.10 Things to Know About Medicaid Managed Care.KFF.2023 Employer Health Benefit Survey.Centers for Medicare & Medicaid Services.What You Should Know About Provider Networks.HealthCare.gov.Health insurance plans and network types: HMOs, PPOs, & more.HealthCare.gov.Out of Pocket Maximum/Limit.Viriyathorn, S., Witthayapipopsakul, W., Kulthanmanusorn, A., Rittimanomai, S., Khuntha, S., Patcharanarumol, W., & Tangcharoensathien, V. (2023).Definition, Practice, Regulations, and Effects of Balance Billing: A Scoping Review.Health services insights,16, 11786329231178766. doi:10.1177/11786329231178766HealthCare.gov.How to appeal an insurance company decision.Consumer Financial Protection Bureau.What is a “surprise medical bill” and what should I know about the No Surprises Act?Centers for Medicare & Medicaid Services.No Surprises Act Overview of Key Consumer Protections.The Commonwealth Fund.States Act to Strengthen Surprise Billing Protections Even After Passage of No Surprises Act.KFF.The Regulation of Private Health Insurance.
12 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Cornell Legal Information Institute.29 CFR § 825.125 - Definition of Health Care Provider.KFF.10 Things to Know About Medicaid Managed Care.KFF.2023 Employer Health Benefit Survey.Centers for Medicare & Medicaid Services.What You Should Know About Provider Networks.HealthCare.gov.Health insurance plans and network types: HMOs, PPOs, & more.HealthCare.gov.Out of Pocket Maximum/Limit.Viriyathorn, S., Witthayapipopsakul, W., Kulthanmanusorn, A., Rittimanomai, S., Khuntha, S., Patcharanarumol, W., & Tangcharoensathien, V. (2023).Definition, Practice, Regulations, and Effects of Balance Billing: A Scoping Review.Health services insights,16, 11786329231178766. doi:10.1177/11786329231178766HealthCare.gov.How to appeal an insurance company decision.Consumer Financial Protection Bureau.What is a “surprise medical bill” and what should I know about the No Surprises Act?Centers for Medicare & Medicaid Services.No Surprises Act Overview of Key Consumer Protections.The Commonwealth Fund.States Act to Strengthen Surprise Billing Protections Even After Passage of No Surprises Act.KFF.The Regulation of Private Health Insurance.
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
Cornell Legal Information Institute.29 CFR § 825.125 - Definition of Health Care Provider.KFF.10 Things to Know About Medicaid Managed Care.KFF.2023 Employer Health Benefit Survey.Centers for Medicare & Medicaid Services.What You Should Know About Provider Networks.HealthCare.gov.Health insurance plans and network types: HMOs, PPOs, & more.HealthCare.gov.Out of Pocket Maximum/Limit.Viriyathorn, S., Witthayapipopsakul, W., Kulthanmanusorn, A., Rittimanomai, S., Khuntha, S., Patcharanarumol, W., & Tangcharoensathien, V. (2023).Definition, Practice, Regulations, and Effects of Balance Billing: A Scoping Review.Health services insights,16, 11786329231178766. doi:10.1177/11786329231178766HealthCare.gov.How to appeal an insurance company decision.Consumer Financial Protection Bureau.What is a “surprise medical bill” and what should I know about the No Surprises Act?Centers for Medicare & Medicaid Services.No Surprises Act Overview of Key Consumer Protections.The Commonwealth Fund.States Act to Strengthen Surprise Billing Protections Even After Passage of No Surprises Act.KFF.The Regulation of Private Health Insurance.
Cornell Legal Information Institute.29 CFR § 825.125 - Definition of Health Care Provider.
KFF.10 Things to Know About Medicaid Managed Care.
KFF.2023 Employer Health Benefit Survey.
Centers for Medicare & Medicaid Services.What You Should Know About Provider Networks.
HealthCare.gov.Health insurance plans and network types: HMOs, PPOs, & more.
HealthCare.gov.Out of Pocket Maximum/Limit.
Viriyathorn, S., Witthayapipopsakul, W., Kulthanmanusorn, A., Rittimanomai, S., Khuntha, S., Patcharanarumol, W., & Tangcharoensathien, V. (2023).Definition, Practice, Regulations, and Effects of Balance Billing: A Scoping Review.Health services insights,16, 11786329231178766. doi:10.1177/11786329231178766
HealthCare.gov.How to appeal an insurance company decision.
Consumer Financial Protection Bureau.What is a “surprise medical bill” and what should I know about the No Surprises Act?
Centers for Medicare & Medicaid Services.No Surprises Act Overview of Key Consumer Protections.
The Commonwealth Fund.States Act to Strengthen Surprise Billing Protections Even After Passage of No Surprises Act.
KFF.The Regulation of Private Health Insurance.
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