Preferred Provider Organization

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Private
Health maintenance organization (HMO) Managed care Medical underwriting Preferred provider organization (PPO)
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In health insurance in the United States, a preferred provider organization (or "PPO", sometimes referred to as a participating provider organization or preferred provider option) 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.

Contents 1 Overview 2 PPO 2.1 California PPO basics 3 Quality of Care 4 EPO 5 See also 6 External links 7 References

[edit] Overview

A preferred provider organization is a subscription-based medical care arrangement. A membership allows a substantial discount below their regularly-charged rates from the designated professionals partnered with the organization. Preferred provider organizations themselves earn money by charging an access fee to the insurance company for the use of their network (unlike the usual insurance with premiums and corresponding payments paid either in full or partially by the insurance provider to the medical doctor).^[1] They negotiate with providers to set fee schedules, and handle disputes between insurers and providers. PPOs can also contract with one another to strengthen their position in certain geographic areas without forming new relationships directly with providers. This will be mutually beneficial in theory, as the insurer will be billed at a reduced rate when its insured utilize the services of the "preferred" provider and the provider will see an increase in its business as almost all insureds in the organization will use only providers who are members.

[edit] PPO

Other features of a preferred provider organization 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. Another near-universal feature is a pre-certification requirement, in which scheduled (non-emergency) hospital admissions and, in some instances outpatient surgery as well, must have prior approval of the insurer and often undergo "utilization review" in advance.

[edit] California PPO basics

In a PPO you get most of your health care from a network of providers, just as you do in an HMO. But you can choose to go outside of the network and pay more. Some Medicare Advantage plans are PPOs, for people with Medicare. There are also Medicare Advantage HMOs.

Primary care doctor: You can have a primary care doctor in a PPO, and it is often advisable to have one, but you do not have to. You can go to a specialist and get other services without seeing a primary care doctor first.

Networks and medical groups: Like HMOs, PPOs have a network of doctors and other providers. However, you can choose to see providers who are not in the network. You usually pay a higher PPO cost to see these providers.^[2]

[edit] Quality of Care

California's Office of the Patient Advocate (OPA) (along with California's Department of Insurance) is releasing a PPO Report Card Fall of 2009. OPA currenlty produces a Health Care Quality Report Card for the top 9 HMOs in California and for over 200 medical groups.

This is part of OPA's effort to create a portal (one-stop shop) for health care quality and transparency for use by Californian's to make informed decisions when choosing and using their health care.

[edit] EPO

An exclusive provider organization (EPO) is a type of managed care plan that combines features of HMOs and PPOs. It is referred to as exclusive because the employers agree not to contract with any other plan.

[edit] See also

• Managed care
• Health maintenance organization
• Point of service plan
• Independent practice association
• Dental plan
• HMO
• Single-payer health care

[edit] External links

• What's a PPO?
• PPO Costs
• PPO Quality of Care

[edit] References