What is a PPO?
PPO stands for Preferred Provider Organization. A PPO is a kind of health insurance or managed care plan.
Networks: Like HMOs, PPOs have a network of doctors and other providers. However, you can choose to see providers who are not in the network. You usually pay a higher cost to see providers who are not in the network.
The providers in the network have an agreement with your PPO that sets a price to provide you a service, like an office visit or surgery. These providers cannot charge you more than the set price. But a provider that is not a part of the network can charge you more.
Check with your PPO plan about its provider network and about costs.
Primary care doctors and medical groups: In most PPOs you are not required to select a main doctor, also known as a primary care doctor or PCP. Some PPOs will ask you to select a doctor or a medical group that will provide most of your care. A medical group is a group of doctors and other providers that contract with a health plan.
Check with your PPO plan about its rules and network of providers.
Referrals and pre-approvals: In most PPOs, you usually can go to a specialist and get certain other services without first seeing a primary care doctor and getting a referral.
You or your doctor may need to get pre-approval from your PPO before certain treatments, procedures, or services are performed.
Check with your PPO plan about its rules regarding referrals and pre-approvals.
Why would I choose a PPO?
- You have a doctor you like and you want to keep this doctor, and the doctor is in the PPO network.
- You want to see specialists and other providers without having to get referrals and pre-approval first.
- You want more of a choice of doctors and hospitals you can go to.
- You want the freedom to see providers who are not in the network. You are willing to pay an extra cost if an out-of-network provider charges more than the PPO's allowed amount.
Why would I NOT choose a PPO?
- You want easier to understand fixed costs (such as a co-pay) instead of a percentage of service costs.
- You do not want to get bills from providers.
- You want to avoid more paperwork related to insurance claims.