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participating



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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