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PPO Insurance Plans

What is a PPO?

PPO stands for preferred provider organization. A PPO is a managed care organization of medical doctors, hospitals, and other health care providers who have covenanted with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients.

Providers in the PPO will provide the insured members of the group a substantial discount below their regularly-charged rates. This arrangement helps ensure that the insurer will be billed at a reduced rate when its insured utilize the services of the "preferred" provider.

PPO vs HMO

People who have PPOs have more flexibility to choose a primary care doctor of their own choice. A person with a PPO will also be able to go to a specialist without first having to get a referral from their primary care physician. PPO members will also be reimbursed (full or partially) if they use a doctor that is not listed in the PPO 'network'.

PPOs are usually more expensive than HMOs.

Exclusive Provider Organizations

Exclusive Provider Organizations (EPOs) are similar to PPOs, except that they do not provide any benefit if the insured chooses a non-preferred provider, except for some exceptions in cases of emergencies. Some state regulations limit how much and under what circumstances an insurance plan can lower the insured's benefit for using a non-preferred provider.

Other features of a PPO generally include utilization review, where representatives of the insurer or administrator review the records of treatments provided to verify that they are appropriate for the condition being treated rather than largely or solely being performed to increase the amount of reimbursement due, a procedure that many providers resent as second-guessing. Another near-universal feature is a pre-certification requirement, in which scheduled hospital admissions and, in some instances outpatient surgery as well, must have prior approval of the insurer and often undergo "utilization review" in advance.

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