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Participating
Many new providers do not understand the benefits of
participating with insurance carriers. Whether or not a provider
participates, or joins the panel, can affect not only how much the
provider is paid, but can also affect his or her patient load.
If
you are a billing service, it is important to be able to advise your
clients as to the benefits or disadvantages of participation with each of
the insurance companies in your locale. The benefits may vary according to
medical specialties.
Generally speaking, patients tend to go to
doctors who participate with their insurance carrier so they know exactly
what they will pay out of pocket. This is usually a copay.
The
provider must then bill the insurance carrier for the service and receive
most of the payment from the insurance company. The provider must then
accept the amount that the insurance company designates as "allowable".
The provider must also abide by all the rules of that insurance carrier
regarding how and when that claim is filed and how the patient is
medically treated. Referrals, authorizations, or treatment plans may be
required. Sometimes it seems as if the insurance carrier makes the
provider jump through hoops to get paid.
You must remember,
however, that the agreement you made with the insurance carrier is a
legally binding contract between the two of you and if you don't follow
these rules, in the least you may lose money on unpaid claims and at the
worst it may be construed as insurance fraud.
Pros
- You are listed in
patient handbooks distributed by the insurance carrier to all the
patients who are covered by the insurance
- Knowing exactly what
the insurance carrier will pay you and approximately how long it will
take you to collect the money
- Most patients look
for providers who participate with their insurance
- Payment is made
directly to the provider by the insurance carrier
Cons
- Insurance carriers
determine your fees
- You must wait for the
payment
- You must abide by the
insurance company's rules
- Insurance carrier may
require extra paperwork
- You may have to
obtain or complete referral forms
- You may have to
submit treatment notes or plans
- You may have to
submit proof of timely filing Payment in many cases goes directly to the
patient
- You must complete the
credentialing application
- You must fit within
the insurance company's guidelines
Overall for most providers it is beneficial
to participate with most insurance plans. There are a few companies that
are just more headaches for the provider than it is worth. You need to
consider your specialty, your patient base, and each individual carrier's
requirements and reimbursement rate when making the decision. There are
actually a few insurance plans that reimburse better when a provider is
out of network. It is rare but it does happen. So make sure you do your
research with each company before making your decision.
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