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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. 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 PPO will be billed at the reduced rate when its insureds 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 only use providers who are members. PPOs have gained popularity because, although they tend to have slightly higher premiums than
586:(EPO) in structure, administration, and operation. Unlike EPO members, however, PPO members are reimbursed for using medical care providers outside of their network of designated doctors and hospitals. However, when they use out-of-network providers PPO members are reimbursed at a reduced rate that may include higher deductibles and co-payments, lower reimbursement percentages, or a combination of these financial penalties. EPO members, on the other hand, receive no reimbursement or benefit if they visit medical care providers outside of their designated network of doctors and hospitals. EPOs do allow reimbursement outside of the network in emergency cases, per the
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performed to increase the number of people due. Another near-universal feature is a pre-certification requirement, in which scheduled (non-emergency) hospital admissions, and in some instances, outpatient surgery, must have the prior approval of the insurer and must often undergo "utilization review" in advance.
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to direct access to non-emergency medical services, and are required to first obtain a referral from their PCP in order to be reimbursed for the cost of medical services inside of their network of designated doctors and hospitals. HMO plans generally have lower cost and lower monthly premiums than
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A preferred provider organization is a subscription-based medical care arrangement. A membership allows a substantial discount below the regularly charged rates of the designated professionals partnered with the organization. Preferred provider organizations themselves earn money by charging an
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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 being largely, or solely, being
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trust funds. By 1982, 40 plans were counted and by 1983 variations such as the exclusive provider organization had arisen. In the 1980s, PPOs spread in cities in the
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PPO plans and HMO members can usually expect to pay less out of pocket to cover medical costs than PPO members.
602:(HMO) in structure, administration, and operation. Unlike PPOs, however, HMOs often require members to select a
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healthinsurance.about.com: HMOs vs. PPOs – What Are the
Differences Between HMOs and PPOs?
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and other more restrictive plans, they offer patients more flexibility overall.
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who have agreed with an insurer or a third-party administrator to provide
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Health
Information Technology for Economic and Clinical Health Act
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Katz, Cheryl (June 1983). "Preferred provider organizations".
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at reduced rates to the insurer's or administrator's clients.
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Medicare
Prescription Drug, Improvement, and Modernization Act
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at the suggestion of Samuel
Jenkins, an employee of the
565:, particularly California due to favorable state laws.
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Comparison to health maintenance organization (HMO)
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Comparison to exclusive provider organization (EPO)
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Health
Insurance Portability and Accountability Act
60:. Unsourced material may be challenged and removed.
164:/ State Health Insurance Assistance Program (SHIP)
549:In 1980, an early PPO was organized in Denver at
322:Emergency Medical Treatment and Active Labor Act
689:"Health Harbor - Health Insurance Plan Choices"
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191:Program of All-Inclusive Care for the Elderly
8:
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352:Patient Protection and Affordable Care Act
340:Patient Safety and Quality Improvement Act
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764:Managed Care: What It Is and How It Works
150:Federal Employees Health Benefits Program
120:Learn how and when to remove this message
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830:"HMO vs. PPO: Which is right for you?"
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871:Health insurance in the United States
665:Ellwein, Linda Krane (15 June 1982).
258:Health insurance in the United States
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58:adding citations to reliable sources
502:participating provider organization
185:Children's Health Insurance Program
25:
767:. Jones & Bartlett Learning.
557:who consulted with hospitals for
69:"Preferred provider organization"
761:Kongstvedt, Peter (2009-10-07).
631:Independent practice association
381:Massachusetts health care reform
34:
791:Preferred Provider Organization
626:Health maintenance organization
600:health maintenance organization
584:exclusive provider organization
494:preferred provider organization
293:Preferred provider organization
287:Health maintenance organization
281:Exclusive provider organization
136:Healthcare in the United States
45:needs additional citations for
18:Preferred Provider Organization
856:Healthcare Network Information
732:10.1080/00325481.1983.11697868
606:(PCP), a doctor who acts as a
500:), sometimes referred to as a
252:Private Fee-For-Service (PFFS)
197:Veterans Health Administration
172:Prescription Assistance (SPAP)
1:
788:Haas, Marjorie Segel (1991).
263:Health insurance marketplaces
27:Type of health insurance plan
227:Health reimbursement account
239:High-deductible health plan
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441:Fair Share Health Care Act
401:Vermont health care reform
216:Consumer-driven healthcare
144:Government health programs
551:St. Luke's Medical Center
506:preferred provider option
413:Municipal health coverage
221:Flexible spending account
806:"Getting Emergency Care"
646:Single-payer health care
419:Healthcare in California
582:A PPO is similar to an
245:Medical savings account
210:Private health coverage
604:primary care physician
598:A PPO is similar to a
449:(Howard Co., Maryland)
233:Health savings account
176:Military Health System
720:Postgraduate Medicine
636:Point of service plan
563:Western United States
522:health care providers
490:U.S. health insurance
424:Healthy San Francisco
156:Indian Health Service
301:Medical underwriting
54:improve this article
588:Affordable Care Act
386:Oregon Health Plan
365:State level reform
314:Health care reform
268:Premium tax credit
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110:December 2007
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65:Find sources:
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43:This article
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876:Managed care
834:Humana, Inc.
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813:. Retrieved
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697:. Retrieved
693:the original
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559:Taft-Hartley
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520:, and other
510:managed care
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434:My Health LA
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275:Managed care
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52:Please help
47:verification
44:
621:Dental plan
555:Segal Group
526:health care
395:Connecticut
865:Categories
815:2020-01-19
699:2011-01-27
652:References
641:Silent PPO
608:gatekeeper
443:(Maryland)
80:newspapers
740:0032-5481
675:14736792M
518:hospitals
615:See also
532:Overview
391:SustiNet
178:(MHS) /
168:Medicare
162:Medicaid
748:6856523
545:History
508:, is a
180:Tricare
152:(FEHBP)
94:scholar
852:(2010)
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354:(2010)
348:(2009)
342:(2005)
336:(2003)
330:(1996)
324:(1986)
277:(CCP)
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235:(HSA)
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187:(CHIP)
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375:Maine
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247:(MSA)
229:(HRA)
223:(FSA)
199:(VHA)
158:(IHS)
101:JSTOR
87:books
769:ISBN
744:PMID
736:ISSN
539:HMOs
492:, a
73:news
728:doi
569:PPO
504:or
498:PPO
488:In
316:law
56:by
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