Gives the policyholders a financial incentive to stay within that network.
One step over the managed care border is the Preferred Provider Organization. PPOs have made arrangements for lower fees with a network of health care providers. PPOs give their policyholders a financial incentive to stay within that network.
For example, a visit to an in-network doctor might mean you’d have a $10 co-pay. If you wanted to see an out-of-network doctor, you’d have to pay the entire bill up front and then submit the bill to your insurance company for an 80 percent reimbursement. In addition, you might have to pay a deductible if you choose to go outside the network, or pay the difference between what the in-network and out-of-network doctors charge.
With a PPO, you can refer yourself to a specialist without getting approval and, as long as it’s an in-network provider, enjoy the same co-pay. Staying within the network means less money coming out of your pocket and less paperwork. Preventive care services may not be covered under a PPO.
Exclusive Provider Organizations are PPOs that look like HMOs. EPOs raise the financial stakes for staying in the network. If you choose a provider outside the network, you’re responsible for the entire cost of the visit.