Health Insurance 101-2 “Participating Provider”

There are two parts to this one.  The first is “participating”.  This means that the insurance company has a contract with someone or something.  The insurance company has agreed to pay directly to this “provider” in a “prompt” fashion.  In return, the “provider” agrees to give the insurance company a significant discount on the charges.

Basically, the insurance company threatens otherwise to wait forever and/ or pay the patient for the service.  Then the “provider” has to try to get the money from the patient.  However, many patients think that the check from the insurance company is money for them to spend.  This is especially true if it is a large amount of money.  The “provider” may be taking payments for years.  The “provider” benefits by getting the check directly from the insurance company. 

We all know that it is corporate blackmail, but nobody can actually prove it.  The insurance company will say that they trust their clients to bring the check directly to the “provider”, and the “provider” must take that risk if they don’t want to “participate”. 

The second part of the statement is “Provider”.  What is a “Provider”?  In health care talk, this can be a pharmacy, a hospital, a home health agency, a chiropractor, an optometrist, a physical therapist, a nurse practitioner, a physician’s assistant, a nursing home……. and maybe a physician.  I didn’t spend eight years in training after college to be lumped with all of these other “entities”.