This article will let you know about the major differences between participating (par) and non-participating (non-par) providers.

Participating (Par) Providers

The physicians or other health care providers that have an agreement with a specific insurance payer are known as Participating providers. The terms and conditions of participation for both the payer and the provider are outlined by these agreements.

There are few implications for participating (par) providers who enter into an agreement with insurance payers. Most significantly, providers must follow the certain rules and regulations set forth by the payer:

• Patient Care Services

The agreement’s patient care services section between a provider and a payer involves information in context to the medical necessity and utilization management. Each and every payer might have their own definition of medical necessity based on the standard definition.

The requirements of utilization management demonstrate the guidelines for gaining pre-authorization, pre-certification, or other requirement designated for the intention of ensuring patient quality and cost control.

• Patient Responsibility

All payers need that the patient be responsible for certain portion of their medical bills. This responsibility is depicted by a deductible, co-payment and/or coinsurance amount. The contract between the payer and the participating (Par) provider also shows that the provider is needed to make every attempt to collect the responsibility of patient.

• Billing Requirements

The billing requirements might differ relying on the provider and the terms specified in the participating (par) provider contract. The details regarding to the coding information, the processing of claims, claim form information, timely filing, medical records and documentation, appeals guidelines, and reimbursements are specified by these requirements.

It will all depend on the payer to decide whether or not to be a participating (par) provider and how helpful it will be in acquiring the targets of the organization

Non-Participating (Non-Par) Providers

The physicians or other health care providers that haven’t agreed to enter into a contract with a specific insurance payer, unlike participating providers are known as Non-participating providers. They might also be termed as out-of-network providers.

“Uncertainty” is the major difference between par and non-par providers. The providers who decide to be non-participating have no guarantee that they will get payment from the insurance payer.

Having the Patient Sign an Assignment of Benefits Form

A form that authorizes the health insurance company of patient to make payments directly to the physician, medical practice or hospital for the treatment received is known as an assignment of benefits form.

While an assignment of benefits has no assurance that a non-par provider will be reimbursed by a payer for services, the provider might be eligible to get payment for the total charges. Non-par providers are not obligated to adjust off or discount any portion of the total charges since they aren’t contracted.

There might be certain exceptions specifically for non-par providers that decide to accept assignment for Medicare patients. Medicare needs that the non-par providers who agree to the assignment accept the non-par allowable as payment in full.

Another drawback of being a non-par provider is that patients are motivated by their insurance company to use only participating providers. This could be restricting to a provider due to the potential number of patients that they might be losing to participating providers.