Why Do Different Health Care Providers Only Work With Some Insurance Providers?

Why do different health care providers only work with some insurance providers? Some insurance companies are easier to work with than others. Some may have less stringent requirements, perhaps straight forward logical paper work, or most importantly, are better at paying health care providers within a reasonable time frame.

The simplistic answer is, "Sometimes [health care] providers are outside of the coverage area that the network may participate in," states Cindy J. Holtzman, Director of Operations at Medical Billing Advocates of America (MBAA). Many medical insurance companies work within a specified area, usually defined geographically. This area may have the boundaries of a region, a state, or beyond. If you happen to live on the outskirts of the coverage area, a health care provider that is local to you may not qualify to be included in your medical insurance network. For example, if your insurance is through your employer but you commute to work (say an hour or two from your home) then most likely the network of the insurance provided will cover the area near your workplace but not necessarily near your home.


The more complicated answer is, "Many insurance companies make it too difficult for the [health care] providers to get payment for the services they render to their patients," says Ms. Holtzman. All of the paper work and the complicated requirements are among the many rigors insurance companies put health care providers through. Some insurance companies are easier to work with than others. Some may have less stringent requirements, perhaps straight forward logical paper work, or most importantly, are better at paying health care providers within a reasonable time frame. Ms. Holtzman recounts an experience with this problem, "It takes too long to get paid. Last year I had an office visit co-payment claim for $85.00, member only needed to pay $20.00. The insurance said [it hadn't gone through] (many times they never received it from me, the Tax ID # is wrong, the address is wrong, etc.) and it took me 25 hours to get the doctor their money. This happens a lot, as an agent, I am always calling on claims that do not get paid and the member does not and should not pay it either." Imagine how much longer this claim would've taken to get resolved without an agent working on it. Health care is a business like any other. Waiting for payment on a costly service causes the burden of looming debt. Anything medical is outlandishly expensive so the stress of that financial burden is daunting.




"With the costs of medical care going sky high, many [health care] providers elect not to join any network because the reimbursement schedule from the insurance company is too low," Ms. Holtzman informs. "There are so many account receivables at doctors' offices. The reimbursement schedule they receive is usually not enough to justify their costs. It could also take extremely long for them to get reimbursed, so it is a time sensitive issue as well as the reimbursement is too little for many providers to accept." All business need to cover their costs so working with any company that pays less than the costs is not a good business move. Understandably, health care providers must be careful when choosing which insurance companies they are willing to work with, if any at all. The business of being a health care provider is an overwhelmingly uncertain endeavor. If it weren't for the fact that you can guarantee there will always be sick people in need of medical care, being a health care provider wouldn't be considered a good business venture.

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