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Why do I Need to Participate With Insurance
Carriers?
Many times, new providers do not fully understand all of the benefits of participating with the different
insurance carriers. The decision to participate or not to participate, has a bigger effect than you might imagine on the overall
earnings potential, as well as the number of clients that a provider can expect to have in the long run.
If you are reading this as a billing service, it is very important to advise your clients of the advantages, as well as the
disadvantages of participating with each of the insurance companies in your region.
Obviously, the benefits may vary according to medical specialties.
Generally speaking, before a patient even decides to make an appointment with a particular provider, they first call to see if
their insurance carrier is on the list that the office accepts. This way, they already know exactly what they will have to pay
out of pocket, and can be financially prepared for the copay that will be required. The provider then bills the insurance carrier
for the service, and will receive the "allowable" designated amount for the particular service from the insurance company.
The provider must abide by 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, and sometimes it seems as if the insurance carrier makes the
provider jump through hoops to get paid.
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Points for You to
Consider
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The insurance
carrier determines your fees
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You must wait for the payment
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You must abide by the insurance company's
rules
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The Insurance carrier may require extra
paperwork
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You may have to obtain or complete referral
forms
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You may have to submit treatment notes or
plans
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You must fit within the insurance
company's guidelines
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You must complete the credentialing
application
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For most providers, it is beneficial to participate with most insurance plans, this process is
called medical credentialing. There are a
few companies that are just more headaches for the provider than it is worth.
In order to make an informed decision, you will need to consider your specialty, your patient base, and each individual carrier's
requirements and reimbursement rate.
* You must remember, that the agreement you make with an insurance carrier is a legally binding
contract, and if you do not abide by the rules that you agree upon, you may lose money on unpaid claims and at the worst it
may be construed as insurance fraud.
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You will be listed in the directory that is
given to every patient by the insurance carrier, which is great advertising for your practice.
You will know both exactly what the insurance carrier
will pay you, as well as how long it will take you to collect your money