Contracted Vs Non Contracted Providers

When it comes to healthcare, there are two types of providers that patients may encounter: contracted and non-contracted providers. Understanding the difference between the two can help patients make informed decisions about their healthcare and avoid unexpected costs.

Contracted providers, also known as «in-network» providers, are healthcare professionals or facilities that have an agreement with an insurance company to provide services at a discounted rate to patients who have that insurance. These contracted providers have agreed to the insurance company`s terms and conditions, including pricing and medical policies. When patients receive care from a contracted provider, their insurance company pays a portion of the cost, and patients are responsible for any co-payments, deductibles, or coinsurance fees outlined in their plan.

Non-contracted providers, on the other hand, do not have an agreement with an insurance company. They may be out-of-network because they do not accept insurance at all or because they are not part of the patient`s insurance network. If a patient chooses to receive care from a non-contracted provider, their insurance company may cover some of the cost, but patients may be responsible for a larger portion of the bill, including any costs that exceed the «usual and customary» rate for that service.

It`s important for patients to understand the difference between contracted and non-contracted providers to avoid surprise bills. One of the main reasons patients receive unexpected bills is because they unknowingly receive care from a non-contracted provider. For example, a patient may go to an in-network hospital for surgery, but the anesthesiologist or radiologist who works with the hospital may not be in-network. This means that the patient will be responsible for paying a larger portion of the bill.

To avoid surprise bills, patients should always check with their insurance company before receiving care. Patients can ask their insurance company for a list of contracted providers in their area and look up providers online to make sure that they are in-network. Patients should also ask their healthcare provider if they are contracted or if they accept the patient`s insurance.

In conclusion, contracted providers are healthcare professionals or facilities that have an agreement with an insurance company to provide services at a discounted rate, while non-contracted providers do not have an agreement with an insurance company. Patients who receive care from non-contracted providers may be responsible for a larger portion of the bill and should always check with their insurance company before receiving care to avoid surprise bills.