Preferred Provider Organization

What is the meaning of a Preferred Provider Organization (PPO)?

A Preferred Provider Organization (PPO) is a type of health plan or where a network of medical providers, healthcare professionals, and clinical facilities provide medical care to insured members or individuals at reduced rates. It is called a preferred provider organization because the healthcare providers, professionals, and healthcare facilities are called “preferred providers.”

You might be wondering how doctors, clinics, and other preferred providers can give members medical care at reduced rates. How do they do it? These providers enter an arrangement with the insurance provider. They negotiate and agree on reduced rates offered to subscribed individuals. In exchange, PPOs give them a fee. Typically, PPO plan members either settle a co-payment at the time of the service or pay until they meet a deductible. 

What are the benefits of a Preferred Provider Organization (PPO)?

A PPO plan provides many benefits to members. For starters, it offers flexibility to members because they are free to obtain medical treatment from providers outside the PPO network. Although this comes at a higher cost to members, it is still an option they can choose. PPO networks are present in many cities and states, which is valuable especially in emergencies. Lastly, PPO plans provide substantial discounts for the medical care of subscribed members. 

What is the meaning of an Exclusive Provider Organization (EPO)? 

An Exclusive Provider Organization or EPO is also a type of health insurance plan. It is similar to an HMO in that an EPO also has a network of physicians and healthcare providers that can provide medical care to EPO members. Much like an HMO plan, EPO plan members can only go to their designated network of doctors and facilities to receive medical care. Any medical treatment obtained outside of the EPO network will not be covered. Because of this, an EPO plan may be a good option for individuals who want to spend less money and who are not anticipating much need for medical care and treatment. 

In an EPO plan, members do not have to go to a primary care physician. In terms of fees, EPOs generally cost less than HMOs and PPOs. 

What is the difference between a Preferred Provider Organization (PPO) and a Health Maintenance Organization (HMO)? 

If you are planning to get either an HMO or PPO, you may be wondering if the two are the same. Well, while they are similar in that they provide medical care to subscribed individuals, there are key differences. 

To begin with, an HMO has what we call a primary care physician or a PCP. This PCP is a member of the local health care network which members must select. Members are required to initially see a PCP for any healthcare concern. The PCP is their first point of contact who assesses their needs and provides a referral if a specialist is needed for the individual’s treatment. In an HMO, members are not allowed to go directly to a specialist. They must see a PCP first and obtain a referral. 

Additionally, in an HMO, members are only covered if they seek medical attention and treatment within the HMO’s designated in-network of doctors, healthcare professionals, and medical facilities. 

On the other hand, in a PPO setup, there is no primary care physician or PCP in the process. Meaning subscribed members can go directly to a specialist without needing to get a referral from a PCP because it is not required. This saves time and effort on the part of the members. Furthermore, PPOs provide more flexibility because subscribed members are allowed to choose doctors and healthcare providers who are outside the PPO network. Although PPOs have their network of physicians and facilities, they do not restrict members from seeing only doctors from this network. 

Finally, let’s compare the expenses. PPO plans generally charge higher premiums than HMO plans because their plans are more comprehensive and they offer a wider range of providers. HMOs are more affordable but individuals are limited to the HMO’s network. 

If you are still on the fence in terms of what health plan to select, make sure to study the differences between an HMO and a PPO. Your decision will highly depend on your needs, budget, and situation.