An intermediary in the context of health insurance, refers to a person, business entity, or corporation that is not directly providing medical healthcare but plays a crucial role in the management of healthcare services. Intermediaries arrange for the delivery of health services by establishing contracts with physicians and other licensed medical providers. This coordination is achieved through agreements both with the medical professionals and a health insurer, facilitating a network of providers that the insurer’s enrollees can access.
Key Functions
- Contract Management: Intermediaries manage and negotiate contracts between healthcare providers and health insurers, ensuring that both parties meet specific terms beneficial for the insured individuals.
- Network Creation: By creating expansive networks of medical professionals, intermediaries help insurance companies offer better geographical reach and varied specializations to policyholders, enhancing the standard and availability of care.
Importance in Insurance Ecosystem
- Intermediaries reduce the complexity for insurance companies in dealing with numerous medical providers individually.
- They support in maintaining a standard of care and controlling healthcare costs, which could be beneficial for premium pricing.
Legal and Regulation Reference
Intermediaries are generally overseen by national and regional insurance regulation acts and regulations. Relevant regulatory framework includes, but is not limited to, sections of healthcare laws and insurance codes that prescribe how intermediaries can operate within the insurance ecosystem, such as the Affordable Care Act (ACA) in the USA.
