What type of provider must accept whatever a payer reimburses for procedures or services performed?

A participating provider is an individual or entity that has entered into a contractual agreement with a health insurance company to provide medical services to policyholders at agreed-upon rates. By becoming a participating provider, they accept the reimbursement rates established by the insurance company for various procedures and services. This means they cannot balance bill the patient for the difference between their usual fees and what the insurer pays; they must accept the payment from the payer as payment in full.

This setup benefits both providers and patients. Patients often face lower out-of-pocket costs and have access to a network of providers who are willing to work within the terms of the insurance reimbursement system. Providers, on the other hand, gain a steady stream of patients who are covered by the insurance plan and can streamline their billing processes due to the agreement with the insurer.

Other types of providers, such as nonparticipating or out-of-network providers, do not have the same obligations or arrangements. Nonparticipating providers may choose to bill patients for the difference between what the payer reimburses and their standard fees, and out-of-network providers may not have any contractual agreements with payers, leading to different reimbursement structures that can leave patients with higher out-of-pocket costs. Value-added providers are not a standard classification