What Is a Healthcare Provider? (2024)

A healthcare provider is a person or entity that provides medical care or treatment. Healthcare providers include doctors, nurse practitioners, midwives, radiologists, labs, hospitals, urgent care clinics, medical supply companies, and other professionals, facilities, and businesses that provide such services.

The term "healthcare provider" is sometimes incorrectly used to refer to a health plan or health insurance company. However, an insurer or health plan administrator does not deliver care. Instead, that entity pays the person or other entity that provides the care (assuming the service is covered by the plan and you've met your responsibilities in terms of referrals, prior authorization, and cost-sharing).

This article explains what you need to know about healthcare providers and how their services interact with your health insurance plan.

Who Are Healthcare Providers?

The healthcare provider you’re probably the most familiar with is your primary care physician (PCP), who gives you primary care services like screenings, vaccinations, and routine exams. There are also specialists that you see when you need certain specific medical care.

There are many different types of healthcare providers. Any type of healthcare service that you might need is provided by one of them.

Not all healthcare providers are physicians or doctors. Here are some non-physician examples of healthcare providers:

• The physical therapist that helps you to recover from your knee injury
• The home healthcare company that provides your visiting nurse (the nurse is also a healthcare provider)
• The durable medical equipment company that provides your home oxygen or wheelchair
• Your pharmacy
• The laboratory that draws and processes your blood tests
• The imaging facility that does your mammograms, X-rays, and magnetic resonance imaging (MRI) scans
• The speech pathologist (speech therapist) who works with you to make sure you can swallow food safely after a stroke
• The outpatient surgery clinic where you had your colonoscopy done
• The specialty laboratory that does your DNA test
• The urgent care center or walk-in clinic in your neighborhood shopping center
• The hospital where you receive inpatient (or in some cases, outpatient) care
• The air or ground ambulance company that transports you to the hospital in an emergency
• The emergency department staff who stabilize you in the event of an accident or serious illness
  

Why Your Healthcare Provider Choices Matter

In addition to your personal preferences about which providers you’d rather have taking care of you, your choice of providers matters for financial and insurance reasons.

Insurance and Healthcare Provider Networks

Nearly all health plans have provider networks (this includes private individual and group health plans, Medicare Advantage plans, and the majority of the coverage that Medicaid enrollees receive). As of 2023, only 1% of employer-sponsored health plans were indemnity plans (which pay a portion of your medical bills but do not replace major medical insurance), as opposed to managed care plans with provider networks.

These networks are groups of healthcare providers that have agreed to provide services to the health plan’s members at a discounted rate and that have met the quality standards required by your insurer.

Your health plan prefers that you use its in-network providers rather than using out-of-network providers. In fact, health maintenance organizations (HMOs) and exclusive provider organizations (EPOs) generally won’t pay for services you get from a healthcare provider that’s out-of-network except in emergency situations.

Preferred provider organizations (PPOs), and to a lesser extent, point of service (POS) health plans, will usually pay for the care provided by out-of-network providers. However, they incentivize you to get your care from their in-network providers by imposing a higher deductible, copayment and/or coinsurance, and out-of-pocket maximum when you use an out-of-network provider.

The Affordable Care Act's cap on out-of-pocket costs is only applicable for in-network care, so health plans can allow much higher out-of-pocket limits (or no limit at all) on out-of-network care, even if they offer coverage for it.

If you choose to use an out-of-network provider, the provider can balance bill you for the portion of their costs that are above the reasonable and customary amount your insurer is willing to pay. (However, as described below, this is no longer allowed for situations in which you essentially have no choice in the provider you use. This includes emergencies as well as out-of-network care received at an in-network medical facility.)

Out-of-Network Healthcare Providers

If you like your current healthcare provider but they’re not in-network with your health plan, you have options that may give you in-network access to your preferred providers.

During your next open enrollment window, you can switch to a health plan that includes them in its network. But this may be easier said than done, depending on the options available to you.

If you're enrolled in coverage provided by an employer, your choices will be limited by the options that the employer provides. If you purchase your own coverage in the individual/family marketplace, your choices will be limited by the plan options and type of coverage that insurers make available in your area.

You can also appeal to your health plan requesting that it cover the care you get from this out-of-network provider as though it was in-network care. Your health plan might be willing to do this if you’re in the middle of a complex treatment regimen being administered or managed by this healthcare provider, or if they are the only local option for providing the treatment you need.

How to Get Out-of-Network Healthcare Providers Covered as In-Network

Another reason your plan might allow this is if you can show the plan why your healthcare provider is a better choice for this service than an in-network healthcare provider.

For example, do you have quality data showing a particular surgeon has a significantly lower rate of post-op complications than the in-network surgeon? Can you show they are significantly more experienced in performing the rare and complicated procedure you need?

If the in-network surgeon has only done the procedure you need six times, but your out-of-network surgeon has done it twice a week for a decade, you have a chance of convincing your insurer. If you can convince your health plan that using this out-of-network healthcare provider might save money in the long run, you may be able to win your appeal.

Healthcare Providers and Federal Protections Against Surprise Balance Bills

Surprise balance bills happen in emergency situations when a patient is treated by out-of-network healthcare providers without having a say in the matter (e.g., they were transported by ambulance to the nearest emergency department, which wasn't in-network with their insurance plan).

This can also happen when a patient is being treated at an in-network facility but receives some of their treatment or services from an out-of-network healthcare provider.

For example, you might have knee surgery at a hospital in your health plan's network, and later find out that the durable medical equipment supplier that the hospital used to source your knee brace and crutches isn't contracted with your insurance plan.

Situations like this often used to result in the patient being stuck with out-of-network bills in addition to having to pay their regular in-network cost-sharing.

Fortunately for consumers, federal rules took effect in 2022 eliminating surprise balance billing in emergency situations and in situations where an out-of-network healthcare provider performs services at an in-network facility.

Ground ambulance changes aren't affected by this new rule (and they account for a significant number of surprise balance bills each year), but the new rule otherwise provides solid consumer protection.

Numerous states had already passed laws to limit patients' exposure to surprise balance billing prior to 2022. However, state regulations don't apply to self-insured health plans, which cover the majority of people who have employer-sponsored health coverage.

The federal regulations, which apply nationwide to self-insured plans and fully-insured plans, provide more substantial consumer protections.

Summary

Your healthcare providers are the people and entities who care for you when you need medical treatment. They encompass the entire team that treats you, including specialists, facilities, and ancillary providers.

Health insurance plans are payers, but they are not providers. Health insurance plans maintain network agreements with a wide range of healthcare providers, and most plans will encourage or require their members to use healthcare providers who are in the plan's network.

While your healthcare providers are obviously important when you're in need of medical care, it's also important to understand the relationship that specific healthcare providers have with your health plan (or any health plan you're considering). You don't want to inadvertently use an out-of-network healthcare provider, as you may find that you owe a lot more for the care than you expected.

It's a good idea to always check with both the health plan and the provider to ensure that they're in-network before scheduling or receiving any non-emergency medical care.