A PPO, is a type of managed care Health Insurance Plan that utilizes a network of physicians and facilities contracted by the Insurance Company to provide services at negotiated price. When a Member receives treatment from a Participating Provider, the only costs that the Member is responsible for paying is a pre-determined Copayment. This type of plan allows for predictable out-of-pocket expenses for the member. The Insurance Company pays the remainder to the provider without further involvement of the Member.
What makes a PPO unique is the ability of the Member to receive treatment from outside the network of physicians and facilities. A member is not limited to the Insurance Company’s list of Providers. However, if a Member is treated by a non-participating provider, the out-of-pocket expenses will be significantly higher. Insurance Companies make every effort to contain costs and urge members to seek services within the network. When services are performed by an out-of-network physician or facility, there is the possibility that the generated bill will be higher than what the carrier is comfortable paying. For this reason, Members utilizing non-participating providers are typically obligated to fulfill a deductible before the insurance company will pay anything, and are also responsible for a larger portion of the remaining balance due.
The most powerful aspect of a PPO Health Insurance Plan is the Member’s ability to seek treatment from any provider at any time. Countless reasons exist that could cause a person to choose services from a physician or facility not contracted with the health insurance carrier. There is comfort in the knowledge that the Member has complete control over the people and places attending to their medical needs.
Another desirable feature of a PPO is the ability to visit specialists without the need for a referral from the Member’s Primary Care Physician. Members insured under a PPO plan do not have to visit their family Doctor before seeking treatment from an specialist.
See any Doctor you want at any time. If they are on the list of Preferred Providers, then you will receive a significantly reduced price, and your PPO Plan will pay a large portion of the bill. If they are not on the list of Preferred Providers, then you won’t get a reduced price, and the Insurance Company will pay a very small portion of that very big bill.