What is a Provider Representative at an Insurance Company?

Also known as a Provider Consultant, a Provider Relations Representative, or a Provider Services representative, these representatives are available to you to provide a deeper relationship than the average call center representative (although they are extremely helpful in their own right!). Insurance companies are serving two different populations: the general consumer who purchases an insurance plan, and the health care providers who are supplying services to the general consumer. Because the insurance company is a middle man between the two different parties, they have separate departments within their organization that handle queries from each group. Provider representatives are employees of the insurance company that are meant to help health care providers understand their relationship with the insurance company, and can work as an advocate for providers within the insurance company. A provider representative is typically someone within the insurance company that you can develop a better professional relationship with, and you can lean on if you have any specific issues with that insurance company.

How do I know who my provider rep is?

When you first credential with an insurance company, you may be provided with information about your provider representative. Be sure that you save this contact information where you know you will be able to find and access it, and that you label the contact with their corresponding insurance company, such as “Blue Cross Provider Rep.” Since you may not find regular contact with your provider representative necessary, the label can help if you eventually do find yourself in a situation where you need to contact the representative.

If you weren’t sent contact information at the start of your contract, you may be able to access your provider representative’s information through an online portal. The insurance company will have sent you information about creating a login for their portal, and once you are in they may have an area where you can access provider representative information. You may also be able to contact them directly through the portal. If you are not in the habit of checking this portal frequently, be sure that you will receive a direct email response or set a reminder to go back into the portal to view any responses.

If there is no information in the portal or you are having difficulty with accessing the portal, you can call the insurance company and reach their provider services department to find out who your provider representative is and get contact information.

What can my provider rep help me with?

Systemic Billing Issues

Provider representatives can be helpful in a variety of ways. If you are experiencing repeated claim denials and rejections and you feel like you’ve exhausted your options of trying to fix the problem, your provider representative may be able to help in identifying why. Typically, it is because some of the information that you are including on the claim does not match what the insurance company has on file for you. A provider rep can help to resolve these issues by either identifying the incorrect information on the claim, or by correcting the information that the insurance company has on file.

Updating Your Contact Information

A provider representative would also be a good person to reach out to if your practice is moving and you have a new address, you are changing your name, or you have an updated email address. Your provider representative can update your profile at the insurance company so that claims will continue to process. Be sure to take note of an effective date for any changes that you make and inform your biller so that they can submit claims with the correct information at the correct time.

Contracted Rates

If you are thinking that you would like to appeal for higher contracted rates with an insurance company, your provider representative would be able to direct you in that process and assist in following up with your appeal. They are not the person who is in control of the rates that the insurance company pays you, however they are a good resource of information about the appeal process. Just because you are working with a provider rep does not mean that you will be successful in increasing your contracted rates, but it can be helpful to make sure that you are approaching the process appropriately under their guidance.

Credentialing Questions and Follow Up

If you are credentialing new clinicians under your practice your provider representative can help in that follow up process. They can keep you in the loop on where applications are at, can inform you of any information that the credentialing team may be missing, or let you know that the application is still in process. Your representative is not the one completing the work on credentialing, they will only be able to provide assistance and information about the process.

Accessing Portals or Online Accounts

If you are having trouble accessing any portal accounts, your provider representative is a good resource to either help you in getting back into the account, or getting it set up in the first place. We would recommend that you try to reset your password online before reaching out to your rep, or follow any instructions that are listed online about account access. If you are still having issues, then it would be best to reach out to your rep.

Advice on New Rules and Regulations

Provider Representatives should be in the know on any new regulations from within the insurance company, and with any new federal regulations that go into effect, such as the No Surprise Billing act that has gone into effect as of January 1, 2022. If you have any questions about how new legislation or rules impact you or how they impact your billing, reaching out to a provider representative is a great place to start. They can either give you answers, or point you in the right direction.

What does a provider rep not do?

Provider representatives are meant to be a liaison between you and the insurance company. They assist with the big picture, and are meant to be a help to you in interacting with other areas of the insurance company. Provider Representatives are not dealing directly with claims processing or credentialing, so don’t send claims or credentialing applications directly to them unless they specifically request you to do so. You will need to follow the proper channels to submit claims or send in an application. If you are unclear about how to do so, that is something that you could ask your rep for clarification on.

It is a good idea to reach out to your provider representative, or find out who they are and set up a phone call or meeting with them to discuss the things that they can and cannot do for you. They may be able to provide you with a list of contacts for anything that is outside of their scope. Having that conversation allows you to get in touch with the right person for the right questions and get answers sooner. It also starts the relationship off on the right foot, and can hopefully help you to have a better experience in working with the insurance company.

A provider representative is a great resource, but they are not able to help you with the day to day billing. Our billers at Practice Solutions can be another great resource for you if you are having difficulty in working with an insurance company. Our billers have years of experience, and can help you in getting your claims processed and paid. Contact us today for more information!