Introduction to Providers

‘Providers’ are individuals or institutes who provide healthcare treatment to patients. Providers are usually doctors, but they can also be nurses, surgeons, x-ray technicians, physical therapists, etc. Although providers are often people; businesses or institutions can also be considered to be providers. 

For example, if someone is admitted to the hospital for an overnight stay, they will likely be treated by many different people. In the eyes of an insurance company (payer), the ‘provider’ in this case is the hospital. Similarly, doctors often form small partnerships for business purposes. These partnerships usually called ‘clinics’ or just a ‘doctor’s office’ are also considered to be providers. 

Providers receive payments for the service they provide, either from health insurance companies (if the patient has health insurance) or directly from the patients themselves.

Individual Providers 

• Physicians (doctors) and nurses
• Surgeons
• Physical therapists
• X-ray and MRI/CAT technicians

Institutional Providers 

• Hospital network: Organization that operates multiple hospitals and clinics offering healthcare service 
• Health system: Organization responsible for delivering care 
• Medical group: Network of physicians who shares resources 
• Hospital: Emergency healthcare service providers 
• Clinics: Non-emergency healthcare providers 

• Every provider/doctor can enroll themselves with insurance payer of their choice, for providing medical service inside their network
• Insurance companies collect documents (educational certificates, medical license, and others) to verify if the provider is eligible to provide services to the patients 
• Then the insurance companies sign a contract with the provider to onboard them into their network to provide service to the patient 
• When a patient consults with a doctor inside the network of their provider it is called in-network provider 
• If any provider doesn’t enroll themselves with the insurance payer, they are generally called out-of-the network
• When a patient consults with the doctor outside the network of their provider it is called out-of-network provider 

• When a healthcare provider has signed a contract with a health insurance company to provide service to the patients, it is referred to as a in-network provider 
• The health insurance company charges a fixed discounted rate to the patient for in-network service
• As this network has a contract between providers and payers, the providers generally charge less due to which the patients will not go to the other doctors out of the network 
• Going out of the network means the patients subject themselves to higher medical charges 
• Also, when a patient has minor health issues, they may just consult with a general physician consultation. So they can get in-network service and save money

• When a patient consults with the doctor outside the network of their insurance company, it is called out-of-network 
• An out-of-network provider does not have a contract with your health insurance company 
• There is no pre-negotiated cost for the service between provider and insurance company, so the cost of the service tends to be high 
• A patient generally gets out of network service when they need consultation from specialists 
• Sometimes a patient has no knowledge that they are taking out-of-network service, so they tend to pay high amount of money 
• For eg: when getting an emergency service, you may need consultation from specialists for which patients may have to go for out of network service, out of town care etc