The physician’s contract with the insurer usually includes
credentialing criteria and establishes reimbursement
rates. The contract also will typically specify whether
the physician is providing primary care or serving as
a specialist. In Health Maintenance Organization
(HMO) and Preferred Provider Organization (PPO)
models, designation as a specialist or primary care provider
will often influence reimbursement rates and determine
whether patients need to be referred to be evaluated
or if they can self refer. It also may influence the physician’s
ability to refer for other services such as imaging
studies and additional specialty consultations. Whether
a physician is designated as a specialist or primary care
provider and other interactions with insurance companies
are complex issues that vary with the insurance model
(Medicare, HMO or PPO), practice location, and practice
model (group or solo). The key point for emergency physicians
considering a practice in SM, particularly outside
of an ED, is the practical reality that they will need to navigate
the same insurance, practice model, and contract
issues as their non-emergency physician colleagues,
unless they choose to work on a cash-only basis
The physician’s contract with the insurer usually includes
credentialing criteria and establishes reimbursement
rates. The contract also will typically specify whether
the physician is providing primary care or serving as
a specialist. In Health Maintenance Organization
(HMO) and Preferred Provider Organization (PPO)
models, designation as a specialist or primary care provider
will often influence reimbursement rates and determine
whether patients need to be referred to be evaluated
or if they can self refer. It also may influence the physician’s
ability to refer for other services such as imaging
studies and additional specialty consultations. Whether
a physician is designated as a specialist or primary care
provider and other interactions with insurance companies
are complex issues that vary with the insurance model
(Medicare, HMO or PPO), practice location, and practice
model (group or solo). The key point for emergency physicians
considering a practice in SM, particularly outside
of an ED, is the practical reality that they will need to navigate
the same insurance, practice model, and contract
issues as their non-emergency physician colleagues,
unless they choose to work on a cash-only basis
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