Jeanette Mercado
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Hello my friend Dr. Campbell asked me if I heard anything about Blue Cross/SISC will no longer pay patient for nonpar visits. Is that true?
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Q&A Chiro - Nonpar question
- Thread starter Jeanette Mercado
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That is correct. The effective date is October 1, 2015. The chiropractor must be a participating provider of the PPO network. There are many other providers that fall into this category as well, such as physical therapists, labs, etc.
Ruth Sheets
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FYI: (for those of us, who are still learning the healthcare jargon and do not know exactly what nonpar means, and had to Google it) the main definition for nonpar = nonparticipating physician, specifically, in the U.S. Medicare program, a physician who does not accept assignment on all Medicare claims. Apparently, it can also mean a practitioner (chiropractor, physical therapist, lab) who is not a participating member of a particular PPO network.
Anything else?
Anything else?
Paul A
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Ruth, I'll add on to that.
Health insurance companies, negotiate rates with providers of medical services. They agree to take discounts knowing the insurance company will limit participation to a subset of providers in a geographic in order to guarantee a volume of patients.
If the provider signs a contract they are considered a Participating (Par) provider.
If the provider does not have a contract they are a Non Participating ( Non-par) provider.
If you have HMO (managed care) plan, you can only see par providers. In these types of plans you have no coverage if you get services from a Non-Par provider. Typically you will have a Primary care physician assigned and they will decide when to allow you to see a Par provider. There cases you can be authorized to go out of the network and see a Non-par provider if the services you need are not available from a Par provider
There are also PPO (and Point of service) plans that allow you to choose if you want to see a Par or Non-Par provider. If you see a Par provider you get lower out of pocket cost. typically 10 or 20% percent of the negotiated rate the provider has with the insurance company. You also have the option to see a non-par provider which typically has a much higher out of pocket expense, typically 30% or 40% of what the provider bills as there is no negotiated rate.
What is happening with these PPO plans is the costs to the insurance company are getting out of control and they would love to get rid of these plans but there is still a demand for it. They are getting creative as they can only raise the premiums (how much you or your employer pays just to have the insurance coverage). The insurance company I work for decided to stop paying what the billed charge is of the non-par provider.We found a vendor who can provide the average cost of procedures in the area and so now anything above that amount is also the patients responsibility. It appears blue cross is deciding to reinvent the PPO and remove the choice of going to a non-par provider all together.
Sorry for rambling on. That came out much more detailed than I planned.
Health insurance companies, negotiate rates with providers of medical services. They agree to take discounts knowing the insurance company will limit participation to a subset of providers in a geographic in order to guarantee a volume of patients.
If the provider signs a contract they are considered a Participating (Par) provider.
If the provider does not have a contract they are a Non Participating ( Non-par) provider.
If you have HMO (managed care) plan, you can only see par providers. In these types of plans you have no coverage if you get services from a Non-Par provider. Typically you will have a Primary care physician assigned and they will decide when to allow you to see a Par provider. There cases you can be authorized to go out of the network and see a Non-par provider if the services you need are not available from a Par provider
There are also PPO (and Point of service) plans that allow you to choose if you want to see a Par or Non-Par provider. If you see a Par provider you get lower out of pocket cost. typically 10 or 20% percent of the negotiated rate the provider has with the insurance company. You also have the option to see a non-par provider which typically has a much higher out of pocket expense, typically 30% or 40% of what the provider bills as there is no negotiated rate.
What is happening with these PPO plans is the costs to the insurance company are getting out of control and they would love to get rid of these plans but there is still a demand for it. They are getting creative as they can only raise the premiums (how much you or your employer pays just to have the insurance coverage). The insurance company I work for decided to stop paying what the billed charge is of the non-par provider.We found a vendor who can provide the average cost of procedures in the area and so now anything above that amount is also the patients responsibility. It appears blue cross is deciding to reinvent the PPO and remove the choice of going to a non-par provider all together.
Sorry for rambling on. That came out much more detailed than I planned.