A patient sitting in the doctor's office might define that who ever takes care of them as a health care professional or health care provider: the doctor, the nurses, the person who draws blood for lab tests, maybe even the health insurer who pays for the visit. Government and the medical industry use more precise definitions. The exact definition varies depending whether you're talking to an insurer, a federal bureaucrat or the American Medical Association.
Health Care Professional or Medical Staff?
The health insurance industry likes to know exactly what sort of medical expert provided what service on your bill. Coding medical records to identify each service and professional involved in your treatment is a profession in itself. The AMA defines a qualified health care professional as anyone suited by education, training and the necessary licensing to perform a medical service. The AMA list of health professionals includes:
- Nurse practitioners.
- Physician assistants.
- Certified nurse specialists trained in a particular field such as E/R, pediatric or diabetic nursing.
- Certified nurse midwives.
- Certified registered nurse anesthetists.
- Clinical social worker. This is a special area of social work focusing on behavioral and emotional problems and mental illness.
- Physical therapists.
The AMA draws a sharp line between these health care professionals and clinical staff. The latter category includes medical assistants, licensed practical nurses and registered nurses. The difference is that even though the staff are trained professionals, they're working under the supervision of a qualified health care professional rather than independently.
When the medical practice or hospital draws up a bill for the insurer and codes for the services the patient received, it identifies each qualified health care professional and their services separately. It doesn't report the staff work as an individual expense. Individual insurers may have specific requirements about the certification they consider makes a health care professional qualified.
What's a Health Care Provider?
From the perspective of most insurers, a health care provider is any one who provides patients with health care. This definition would include every one in the AMA's list of health professionals but it's much broader:
- A home health care company that sends a visiting nurse to a patient's home.
- A medical equipment company that makes oxygen tanks or wheelchairs available.
- Medical laboratories.
- Imaging facilities that process mammograms and MRIs.
Each insurance company maintains its own network of providers. If a patient goes outside the network to a different health care provider, the insurer may not cover as much of the bill, or any of it. A recurring problem for patients is that even if the hospital or clinic they use is in-network, one of the providers it contracts with, such as a medical-equipment company, comes from outside the network. That can send the patient's share of the bill rocketing.
Federal regulations define "health care provider" differently." The federal list includes:
- Doctors of medicine.
- Doctors of osteopathy.
- Clinical psychologists.
- Chiropractors, but only if they're fixing a back alignment problem that's been identified on an X-ray.
- Nurse practitioners, nurse midwives, clinical social workers and physician assistants.
- Christian Science practitioners, who treat health issues with prayer. Practitioners have to be officially listed with the First Church of Christ, Scientist.
- Any other health care professional if the patient's employer or insurer will decide coverage and benefits based on the professional's medical opinion.
An individual health practitioner is only qualified to be a provider if they have whatever licenses or certifications the laws requires. A doctor who loses their license, for instance, is no longer a health care provider under federal law. Professionals are only qualified when they're working within their skill set. A dentist, for example, is a health care provider when they work on teeth but not if they get the itch to give someone back surgery. A degree in dentistry doesn't qualify someone for that.