Non-Participating Provider
 (Out of Network)

Providers that choose not to participate in a health insurance carrier’s network of doctors are called non-participating or out of network providers.

Choosing to opt out of participation with a particular health carrier may not mean that a provider does not participate with any health plans. For example, a provider may be participating with Blue Cross Blue Shield but choose not to participate with Cigna. It is totally up to the provider to decide.

A provider may choose not to participate with a health carrier for a lot of reasons including:

  • Maybe the patient demographic just doesn’t support the need to participate with a particular network. For example, the provider treats, primarily, Medicare patients of which they are participating, so they see no reason to add other networks.
  • A provider may opt not to participate in a network despite the possibility of an influx of new patients because it may not be enough to offset the loss in income due to low contracted rates.
  • The service provided has little competition. For example a durable medical supplier may have an item that is unique and necessary so that patients will contact them, whether in network or out. This was the case a few years ago with the power scooters. Patients wanted one and they were willing to go out of network to buy one.     
  • The provider is currently out of network and they see no reason to change things.
  • Non-participating providers have the option of billing the patient for any amounts not paid by the health plan. This means that they are assured that all billed claims will be paid in full. They are unwilling to reduce their profits by accepting the health carriers allowed amounts.

To remain out of network is simple, they just don’t enroll. Their name will not be listed in any of the provider directories. So how does a non-participating provider gain patients? Well, patient access could be based upon:

  • Location of the provider, maybe they are part of a busy medical center.
  • By referral from one provider to another.
  • By patient word of mouth.
  • By some form of advertising.  

Since selection by provider directory is so random anyway, no one can really predict the number of patients that any provider may have access to using this method alone.

In a nutshell

The decision whether to participate in a network is totally up to the provider. Some providers may choose not to participate with a particular health carrier or may choose not to participate with any health carriers.

I think the jury is still out on whether the access to new plan members really does balance out the loss in income due to the low contracted rates.

It is assumed that choosing to remain out of network will affect a provider financially because patients are just not willing to pay the higher out of network costs; especially if there is a provider, in network, that can provide the same service. Also, some plans are written to provide no access to an out of network provider. This means that a patient will receive no reimbursement, at all, for any service performed by an out of network provider. 

But we must not underestimate the draw of a good doctor. A physician who knows all aspects of your health, or who has been part of your family for years has a certain appeal that cannot be discredited. I know people who are willing to pay the higher out of pocket costs, just to keep their doctor. A good doctor who sees you as a person and not an ailment is a special quality, to some, and may be worth the extra costs associated with continuing being treated by them. 

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