American Academy of Professional Coders (AAPC) Practice Exam

Who are non-participating providers?

1. Providers contracted with insurance carriers

2. Providers who accept any payment amount

3. Providers not contracted with the insurance carriers

4. Providers who primarily work with governmental entities

The correct answer is: Providers not contracted with the insurance carriers

Non-participating providers refer to those healthcare providers who do not have a contract or agreement with specific insurance carriers to accept the insurance company's payment terms. This means that they are not part of the network established by those insurance companies, which can result in these providers charging patients directly for their services, often at higher rates than those set by participating providers. Non-participating providers may bill patients for the full amount of their services and expect the patient to submit a claim to their insurance company for reimbursement, instead of billing the insurance company directly. This contrasts with participating providers, who have agreements with insurers to accept predetermined payment rates and often have billing arrangements with these companies. The other options focus on providers with different relationships to insurance carriers. Providers contracted with insurance carriers are considered participating providers, while those who accept any payment amount may indicate a level of flexibility in payment but do not specifically define a non-participating status. In addition, while providers who primarily work with governmental entities could potentially be non-participating, this does not encompass the broader context of the definition, as non-participating status is specifically tied to the relationship with insurance companies rather than the type of entities they work with.