As you start to use your insurance, you may hear the term “provider” used frequently. So, what is a provider and why does it matter when trying to keep your healthcare costs down?
Let’s start with the definition: A provider is anyone who provides a direct health care service to you, the patient. Providers are paid by your insurance for the health care services they provide. Whatever is not paid by your insurance will typically be billed to you.
The main provider you will likely interact with is your Primary Care Provider (PCP). This could be a family doctor or pediatrician that you or your child see regularly for well visits or to manage chronic conditions. Providers also include medical specialists, like cardiologists, obstetricians, neurologists, and psychiatrists.
So why don’t we just call them “doctors?” Heath care “provider” is a much broader term, encompassing the many professionals who might provide you with care. Here are some examples:
- Nurse practitioners, who can see patients and prescribe medications & testing;
- Podiatrists, who treat feet & ankles;
- Physical therapists, who can help you recovery from injuries or procedures;
- Chiropractors, who can adjust your spine;
- The laboratory that draws your blood for a medical test;
- Pharmacists, who fill your prescriptions;
- Optometrists, who make sure you have the right glasses or contacts; and
- The company that sends you medical equipment, like a wheelchair.
So why is this important when accessing care? You may also hear the term provider when referring to who is in your provider “network.” These providers have agreed to a set price for various services with your insurance company in order to lower your out-of-pocket costs. There are also providers who are out-of-network and do not have those agreements, so there is a higher cost for you.
If you want to make sure you know what you’ll pay for healthcare services, it’s important that you check to make sure any healthcare provider who cares for you is in your insurance plan’s network before you receive services. You can check by calling your plan’s member services, looking up the provider online on the provider’s directory, or calling the provider directly and making sure they accept your plan. Be sure to ask if they are in a certain tier within the network. If you choose to use the online directory, make sure you document what you find by taking a screenshot as online directories can be out-of-date.
If you need help figuring out whether a provider is in your network, contact our helpline: 877-570-3642. We can walk you through it!