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PCP vs Specialist

How to choose the correct one

I'm often asked what the difference is between listing a provider as a PCP vs. a Specialist. Can you choose whichever one pays better? Is it a big deal if you choose the wrong one?

First, let's look at the differences between PCPs and specialists. 

Primary Care Providers (PCPs)

A PCP is a doctor who provides general medical care for people of all ages. They are the first point of contact for any health concerns, and they can offer a wide range of services, including the following:

  • Preventive care includes physical exams, vaccinations, and screenings for cancer and other diseases.

  • Diagnosis and treatment of common illnesses: PCPs can diagnose and treat various diseases, from colds and flu to allergies and high blood pressure.

  • Management of chronic conditions: PCPs can help manage chronic conditions like diabetes, heart disease, and asthma.

  • Referrals to specialists: If the PCP thinks a patient needs to see a specialist, they will refer the patient to the appropriate doctor.

Specialist Providers

A specialist is a doctor who has completed additional training in a specific area of medicine. They have a deep understanding of a particular organ system or disease and can provide more specialized care than a PCP. Some common types of specialists include:

  • Cardiologists: Cardiologists specialize in the heart and blood vessels.

  • Dermatologists: Dermatologists specialize in the skin, hair, and nails.

  • Gastroenterologists: Gastroenterologists specialize in the digestive system.

  • Neurologists: Neurologists specialize in the brain and nervous system.

  • Obstetricians/gynecologists (OB/GYNs): OB/GYNs specialize in women's health.

Patients see PCPs for most of their routine medical care. PCP will get to know the patients and their medical history, and they will be able to provide the patients with comprehensive care. However, there are some times when the patient may need to see a specialist. These include:

  • The patient has a complex medical condition.

  • The PCP cannot diagnose the patient's condition.

  • The patient needs specialized treatment for their condition.

When you list the provider as PCP or specialist, that is the type of contract you will receive from the insurance company. Each provider's contract will have its fee schedule based on the provider's taxonomy and provider type. 

Now that we've reviewed each type of provider, let's look at the dos and don'ts of listing the provider type with an insurance company.

- Do list the provider as a PCP or specialist based on the services the provider will offer. 

Do consider the provider's taxonomy (NP, MD, PA, PT, DC) 

Do not choose to list your provider as a PCP or specialist based on fee schedule. You could be in trouble if you list a provider as something they are not and you are audited. You face having to pay back the money the insurance company has already paid you for that provider, risk losing your contract with the insurance company, and potentially being banned from the insurance company. 

Do not choose a provider type based on what other clinics do because that's what they say pays well. Just because someone else is doing it and getting paid doesn't make it the right thing to do for your clinic. Always research and choose based on what is accurate for your clinic. 

Since this is how your contract is written, it's crucial that you list the provider correctly and accurately. If you're already credentialed with an insurance company, this can help you understand the fee schedules better. Credentialing and billing are closely connected; knowing how a provider is credentialed can help the billing go smoother.

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