Preferred Provider Organizations (PPO) are one of the most popular types of plans in the group insurance marketplace. PPO plans allow you to visit any physician you choose regardless if they are in the network or not.
An insurance company will offer many different PPO plans. A consumer considering enrolling in a PPO needs to conduct a personal cost analysis by determining how often they go to the doctor and how much they want to have covered as well as factor in an amount of risk. Typically, higher coverage and lower deductibles accompanied by lower co-pays for doctor office visits will mean higher monthly premiums and vice versa. Below are some common concerns that we come across in working with PPO plans:
- The mistakes of a PPO plan holder can be costly. Benefits change drastically when the member goes “out of network” which refers to receiving services from a non-participating physician. While a given procedure may be covered 90 percent in network, the same procedure may only be covered 50 percent out of network. Verification of participation should be confirmed before any major surgery or procedure. Often times, a patient’s doctor and hospital can be in network but the anesthesiologist is not. This can result in costly, unexpected charges.
- It is important to remember that your PPO provider is generally unaware of what your benefit schedule is. That fact that a provider recommends a procedure does not guarantee that it is a covered benefit, nor a comment on how much the carrier might reimburse you. If you are not sure if a certain procedure will be covered, the best option is to call the carrier directly.
- Certain procedures may need pre-authorization from the carrier. While it is usually the provider’s responsibility to do this, it is important to call the carrier to confirm that all necessary paperwork has been approved before proceeding with care.
- If you are concerned with any potential out-of-pocket costs for a certain procedure, customer service can assist with that. To do so, you will need to have the name and address of the provider who will bill for the treatment and the diagnosis and treatments codes that the provider will use.
- Customer service cannot answer very general questions, such as “how much does knee surgery usually cost”?
- Be aware that if you are admitted to a PPO hospital, this only guarantees that the actual inpatient hospital stay will be processed as a PPO claim. There is no guarantee that any providers working under the umbrella of the hospital (and bill out under their own Tax ID Number) are also PPO providers. This may happen with anesthesiologists, Emergency Room doctors, radiologists, pathologists, or surgeons. If you are treated in a PPO hospital by non-PPO providers, you will usually be billed for out of network benefits.
- The best time to locate an urgent care center is before you actually need it. For PPO providers, you can all Customer Service or check online. Keep the information in a convenient place.
- If you have an urgent care situation that is not a true emergency and are looking to minimize OOP costs, try to seek treatment at a standalone urgent care center (one not associated with a hospital). Urgent care centers in a hospital setting are often billed out as emergency room visits.
- Because PPO providers are generally contracted with multiple carriers, they may not necessarily be aware of the details of each carrier’s network. If your provider refers you to a specialist or a lab, for example, this is not a guarantee that these are also network providers.
It is your responsibility to check first before you receive treatment. The best way would be to check online, call the carrier directly or have our office assist you in the process.
Jay is a graduate of the University of Pennsylvania School of Dental Medicine and also has an MBA from San Francisco State University. He has worked for a number of insurance carriers and brokers over the past 25 years. At UBF, Jay specializes in advocating for our clients in various issues, including grievances, benefit inquiries and eligibility issues.