American Academy of Professional Coders (AAPC) Practice Exam

When is a physician considered a "participating physician"?

1. When contracted with a governmental entity only

2. When contracted with a private insurance company only

3. When contracted with an insurance carrier

4. When providing services to any patient

The correct answer is: When contracted with an insurance carrier

A physician is considered a "participating physician" when they have a contract with an insurance carrier. This contract often specifies that the physician agrees to provide services to patients covered by that insurance plan at negotiated rates. By participating in a network, the physician typically benefits from a steady stream of patients and can offer their services at a cost that is often lower than their usual charges. Being a participating physician also generally means the provider has agreed to follow certain guidelines and billing practices set by the insurance carrier, which could include predetermined fees and potentially restricted treatment protocols. This relationship is beneficial for both the physician and the insurer, as it helps the insurance company manage costs while ensuring that patients have access to a range of providers. Other options describe contracts with specific entities or general patient service scenarios, which do not capture the essence of what defines a participating physician. Being contracted specifically with an insurance carrier is the defining characteristic that establishes this status.