I'm confused by all of the insurance terms. What is the difference between a participating provider, a non participating provider and an opted our provider?
These terms mean different things depending on whether you are talking about a commercial insurance plan or Medicare.
A participating provider is a provider who has a contract with your insurance company. The physician is also called an in-network provider. Under the terms of the contract, the provider agrees to accept certain amounts for performing certain procedures. After the provider submits the bill for his or her services, the insurance company will look at the bill and separate the bill into allowable amounts and disallowable amounts. Under your contract with the insurance company, you will have to pay a certain amount of the allowable amount. The set fee that you pay each time you visit the doctor is called the copay. The coinsurance is any additional amount or percentage of the allowable charge. If you have an HMO or an ACC type of plan, your insurance company will only reimburse for visits when you see participating providers or in-network providers.
A provider who participates with Medicare is a physician who has, for lack of a better word, a Medicare contract and who accepts assignment for Medicare patients. When a physician accepts assignment, the physician agrees not to charge the patient for her services on the day of the service, but to wait 30 to 60 days for Medicare to pay her. This provider will receive 100% of the Medicare allowed amount for services that are deemed medically necessary.
A physician who doesn’t participate with your insurance company is simply a physician who doesn’t have a contract with your insurance. That does not mean that the physician won’t accept your insurance. It simply means that the physician does not have a contract with that insurance company. If you have a PPO plan or a Preferred Provider Plan that permits you to see non participating or out of network physicians, your insurance plan will reimburse you for some of your medical visit. The reimbursement will be less than if you went to a participating provider. How much you will receive will depend on the provisions of your plan. A non participant provider may or may not agree to submit your claims and he or she may or may not accept assignment of your benefits.. In other words, if the provider doesn't accept assignment, then you will have to pay the provider and the insurance company will reimburse you any sums they would have paid.
A non-participating provider is a physician who has a “contract” with Medicare, but has chosen not to participate. When a physician chooses not to participate, he is giving himself the option to charge more for Medicare services. If this physician accepts assignment of benefits, in other words, if he agrees to be reimbursed by Medicare, he will receive only 95% of the Medicare allowable amount. If however, the physician does not accept assignment, but receives payment from the patient at the time of service, he may bill up to the limiting charge, which works out to be 109% of the Medicare allowable amount. A non participating physician, just like a participating physician must submit the claims to Medicare. If the physician doesn’t accept assignment, Medicare will reimburse the patient within thirty to sixty days.
Opted Out Provider
This term is significant only with respect to Medicare. An opted out provider is a physician who is not contracted with Medicare. When a physician chooses to opt out of Medicare, he or she can never submit claims to Medicare and can never be reimbursed by Medicare. If a Medicare patient wants to see an opted out physician, the doctor and patient must enter into a contract which details that neither the physician or the patient can ever receive reimbursement from Medicare.
I have Medicare and someone told me that if I see a non participating provider, I will have to pay for everything when I see that provider?
Individuals, even medical personnel often misunderstand the difference between a participating, a non-participating and an opted our provider. You will pay for the full amount of your visit without any reimbursement from Medicare only if you see an opted out provider.
I’m having a surgery, will I have to pay more because you are a non participating provider?
When you have a surgical procedure, most of the fees actually go to the surgical center and not to the doctor. The amount you will pay to Pain Solutions is completely separate from what you will pay to the facility. We will let you know how much it will cost on our end. How much it will cost with respect to the facility depends on whether that facilty is in network with your insurance company.
If you don’t participate with my insurance, may I still see you?
You can come and see us no matter what insurance you have.
The real question is whether the insurance company will reimburse you or Pain Solutions for your visit. That depends. If you have a medical insurance policy that allows you to see out-of-network providers, then you may see me and either submit your claims yourself and have the insurance company reimburse you, or you may ask me to submit the claims for you.
If your benefits limit you to participating providers, then you can only be reimbursed for visits to in-network providers.
That doesn’t mean that you can’t choose to self pay for certain types of visits. Sometimes, you will find, that it may be cheaper for you to go to an out-of-network provider and self pay than it will be to go to an in-network provider. While these situations are rare, they certainly do happen. If you have questions about how much something will cost, please call us and we will be happy to tell you.
If you don't participate with my insurance, how much will I have to pay?
Please call us at 505-247-9700 and we will be happy to provide you with an estimate.