You maintain all the licenses and fulfilled all the requirements which permit you to practice clinically. How do you get paid for services you render?

Healthcare is uniquely unlike the myriad of other industries that supply a service or product to a customer and receive payment directly from that customer. It is rare that a customer (patient) for a healthcare service pays a healthcare provider (hospital, physician, nurse practitioner, PA, etc.) directly for services. Patients for health care services are typically covered by a health insurance plan purchased individually or by their employer, or by a government health plan such as Medicare (for the elderly and disabled), Medicaid (for the indigent) or TriCare (for the military and dependents). The health plan (typically known as a third party payer) pays the health provider on behalf of the patient. Payment for a healthcare service is typically negotiated by a third party payer with the health care provider. The patient may be responsible for contributing a component of the payment (commonly referred to deductibles and co-payments) depending on the requirements of their health plan.

Since the preponderance of payments to healthcare providers are made by third party payers, a healthcare provider, in many instances, will need to be enrolled (think credentialed and recognized) by those third party payers to receive payment (or, in the parlance of healthcare, reimbursement). Enrollment (participation) is a contract with a health plan that has multiple implications which may include: establishing the credentials and requirements to join the health plan and maintain enrollment; adding you to the approved providers for a health plan; accepting the fee schedule or payment methodology of that payer (and the patient deductibles and co-payments); accepting the clinical protocols for practice; and delineating the healthcare provider responsibilities toward members of the health plan.

Certain health plans may pay a healthcare provider who is not enrolled within that health plan’s network (generally referred to as “out of network”). Instances of payment “out of network” may be for emergency services, inpatient hospital services or other defined healthcare services. Payment for such services may be at a different rate (non-participating) for the healthcare provider or have higher patient responsibilities (deductibles and co-payments).

Lastly, a health provider can be recognized on two levels by a health plan. Enrollment in a health plan provides participation on an individual basis. Individual participation keys on your social security number for payment, your NPI as the health provider rendering services and typically an individual health insurance plan PIN (in certain instances, the PIN and NPI can be the same). An individual health provider may take their individual enrollment with a health plan and join that participation with a group (or multiple groups) that also participates with that health plan. When an individual health provider joins a group, payments for health services are made under the group’s Federal employer identification number (EIN), utilizing the individual health provider’s NPI as the rendering provider of service.

The selection of payer enrollments and the timeliness of completing these enrollments is a critical component of practice. Select Medicare, Medicaid or commercial payer to complete your individual enrollments.