Participating Provider
(In Network)

Today, it is almost impossible to find a medical provider that does not participate with at least one health insurance carrier.

So what does this mean?

Most managed care plans are designed to deliver a two-tiered approach to the delivery of healthcare, in network and out of network.

In order for this concept to work it must:

  • Have a large selection of participating providers (of all specialties, nationwide, small cities and large) for patients to choose from.
  • Provide an incentive for a patient to want to use a participating provider.
  • Provide an incentive for a provider to want to participate.
  • Be delivered in way to control costs while still providing great care.

So it all starts with a network

Health insurance carriers are in the business of writing and administering health plans but they are also in the business of provider enrollment. A large, diverse, network of providers is critical to their ability to bring on new groups, keep customers satisfied and retain the business they have.

Providers must also provide great medical care to the patients that they treat. In order to afford to stay in business, they have to be open to the concept of plan participation because it helps to drive the constant flow of patients needed to stay in business and stay profitable.     

Plan members in group plans usually will have no input into the plan that is ultimately selected for them.  They will simply enroll, then figure out how to make that plan work for them. Provider selection is key. Plan members want to have access to medical providers, of all specialties, located in their neighborhood. They also want a huge network of medical providers to choose from so that the wonderful doctor they have had for years, that their family loves, is part of their plan network and they will not have to switch.

When a provider decides they want to participate in a health carrier’s network, the process is fairly simple, they can contact the carrier online, click the provider enrollment button and get the process started. 

As part of the process, the provider will agree, by signature, to ALL of the rules to participate, some of which may include; thou must provide quality care, accept the plan allowed amounts, agree not to balance bill the patient over the allowed amount and  know how to handled disputes.

Once all of the paper work is completed, the provider is now a participating provider and their name will be listed in the provider directory. All plan members have access to the plan’s provider directory, either online or hardcopy. This directory lists all providers, by area and specialty and is the go-to place when a plan member is trying to locate a medical provider.  

In a nutshell

It is almost mandatory that a provider participate in at least one health plan since most plan members are enrolled under some type of managed care plan. This is the best way for a provider to ensure that a patient will find them when they need care.

It is not unusual for providers to participate with numerous health plans at the same time and as such will be listed in the directories of all of these carriers. This ensures that they will have access to patients under a wide variety of health plans. A doctor can be participating with Aetna, Cigna and United Health care at the same time and will be able to treat patients who are insured with all of these plans.

It really is all about expectations. A provider can expect lower reimbursement in exchange for access to more patients. A patient can expect higher reimbursement and less out of pocket costs. Lastly, a health carrier can expect some control over healthcare costs.

Back to Chapter Three

Next to Non-Participating Provider