What Organization of Doctors and Hospitals is a Combination of Traditional Fee-For-Service and a Health Maintenance Organization?
A Preferred Provider Organization (PPO) is a managed care organization type, and is different from an HMO. It uses traditional-fee-for-service mode of payment. Moreover, it is an organization for managed care from medical professionals, contracted by an insurance company to give health care at affordable rates to its clients or patients.
Moreover, it gathers physicians, hospitals, and other providers of health care who have contracted with an insurer and gives health services to the clients of the insurer at lower rates.
It also provides medical care that is subscription-based. As such, it allows a considerable discount, different from the usual charged rates of the particular professionals connected with the organization. PPO themselves gain money by charging an access fee to the insurer for using their network (of medical professionals and institutions). Insurance companies deal with provider to set the schedule of fees, and manage disputes between insurance companies and providers.
Aside from that, PPOs can also bargain with one another to reinforce their position in some geographic areas without establishing new relationships with providers. In theory, this is mutually beneficial since the insurer will be charged at a reduced rate when its insurance companies use the services of the “preferred” provider, and the provider will notice an increase in its business, since almost all, or those insured in the organization will only utilize providers who are members. PPOs became popular during the past decade for, even though they tend to have bit higher premiums those HMOs and other restrictive plans, they present better overall flexibility for its patients.
Also, PPOs basically include utilization review. Here, the representatives of the insurer or administrator evaluate the given treatment records in order to confirm that they are fit for the condition being treated and not just hugely being carried out to add up to the patient’s reimbursement due. Another one of its near-universal characteristics is a requirement of pre-certification. With this, scheduled or non-emergence hospital cases or admissions, and at times, outpatient surgery needs to have approval first of the insurer and usually undergo “utilization review” before hand.
EPO, short for Exclusive Provider Organization, is a kind of managed care plan which combines features of both HMOs and PPOs. It is described as exclusive since the employers agree not to have any contract with other kinds of plan.
Fortunately, there is a flexibility of looking for care with an out-of-network provider, with a PPO. However, it is more a patient’s out-of-pocket expense. You don’t need to have a referral in order to see a medical professional. The members of the PPOs are not required to visit a primary care physician (PCP in order to get their benefits which are in-plan.
The networks of PPOs also have prescription services that give prescription drugs at a less-expensive cost. The total premium for a PPO is less than for health coverage for an individual. Another, this will also include more medical services that are covered. There is also a wide network of medical providers that represent large geographic areas.