Which Healthcare Providers or Healthcare Facilities Accept Insurance Varies

Your Options When a Provider Won't Accept Your Insurer

When it's time to find a healthcare provider, whether you need primary care or a specialist, your choices are limited by healthcare providers who are willing to work with your chosen health insurance. One healthcare provider may accept your payer while another won't. Learn more about how this may affect your healthcare choices.

A receptionist at a doctor's office
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How Insurance Works

Understanding how health insurance works will shed some light on why your insurance isn't accepted by all medical care providers.

Each year, healthcare providers and healthcare facilities like testing labs, hospitals, and pharmacies negotiate pricing with health insurers and payers. In its simplest form, it goes like this:

Healthcare provider: When a patient with diabetes visits my office, I charge $100 for the visit and $75 for the blood work.

Payer: That's too much money. We'll pay you $55 for the visit and $35 for the blood work.

Healthcare provider: I can't pay my staff or keep my lights turned on for that paltry amount. How about $65 for the visit and $45 for the blood work?

Payer: Deal.

That negotiation takes place for every possible service your healthcare provider performs, with every insurance company, each year.

Some insurance companies refuse to pay some healthcare providers the amount those healthcare providers believe they are entitled to be paid. When that happens, the healthcare provider will stop accepting that form of insurance as reimbursement.

Then, of course, once the healthcare provider no longer accepts that insurance company's reimbursement schedule, then she no longer accepts patients who use that payer's insurance.

Rationale Behind Whether Insurance Is Accepted or Not

You don't have a voice in whether a healthcare provider should, or should not, accept the amount of money a payer is willing to pay. For one reason, the U.S. has a free enterprise system of healthcare payment. Each private practice, hospital, lab, or facility has a right to charge what it wants to charge, and which payers it wishes to work with.

Here's another way to think about it. Suppose you went to work and did your job well. When it came time to get your paycheck, your employer told you he had decided your services weren't really worth what you expected to be paid, so he was going to begin paying you less. Take it or leave it. That's the position healthcare providers are put in by payers each year.

If a payer reimbursed at the higher amounts a healthcare provider wants to be paid, it would cost patients more in the forms of premiums, co-pays, higher deductibles, and sometimes taxes, too.

How to Be Sure Your Insurance Will Pay for the Healthcare Provider You Want

Be aware that healthcare providers may change plans. Or, insurers and payers may add or drop healthcare providers from year to year. Whenever you make an appointment or change insurance plans, it's always good to double check whether you will be able to see the healthcare providers you usually see.

  • If the healthcare providers you want to see are more important to you than what it costs to visit them, then contact their offices and ask which insurance payers they will accept reimbursement from. Then choose from among the plans they accept. It's possible they accept only some plans from an insurer, and not all, so be sure to ask them to list the specific plans they accept.
  • If you are limited to only some insurers or some plans, then check with those plans to see which healthcare providers are on their lists of providers. This information is often found on the payer's websites, or you can call their customer service phone numbers to ask.

What You Can Do if You Want to See a Specific Healthcare Provider Not Covered

You have options if your healthcare provider won't accept your insurance.

  • Pay cash for the visit. Be sure to make this arrangement ahead of time, though. Not all healthcare providers will accept cash payments.
  • Find a healthcare provider who runs a concierge or boutique practice. These healthcare providers don't accept insurance in most cases. Since you pay them cash anyway, insurance doesn't have to be a consideration.
  • See an out-of-network healthcare provider even though you will have to pay more to see him or her. Just be careful to track the billing and be sure you are not balance billed beyond what should take place.
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Article Sources
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  1. Fontes R. Negotiating contracts with insurance companies. HCP Live. August 16, 2013.

  2. Heath S. How concierge medicine affects patient care, financial responsibility. Patient Engagement HIT. January 23, 2018.