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20-September-2008 09:29:10 - Preferred provider organization December 2007 Health care in the United States Government Centers for Medicare and Medicaid Services Medicare Medicaid TRICARE Department of Veterans Affairs VA Indian Health Service State Children's Health Insurance Program SCHIP EMTALA Federal Employees Health Benefits Program Private Health maintenance organization HMO Managed care Medical underwriting Preferred provider organization PPO Private consumer driven Flexible spending account FSA Health Reimbursement Account Health savings account Medical savings account High Deductible Health Plan HDHP Others Canadian and American health care systems compared Health care reform in the United States Single payer health care Uninsured in the United States Universal health care This box: view talk In health insurance, a preferred provider organization or PPO, sometimes referred to as a participating provider organization is a managed care organization of medical doctors, hospitals, and other health care providers who have covenanted with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients. The idea of a preferred provider organization is that the providers will provide the insured members of the group a substantial discount below their regularly-charged rates. This will be mutually beneficial in theory, as the insurer will be billed at a reduced rate when its insured utilize the services of the preferred provider and the provider will see an increase in its business as almost all insureds in the organization will use only providers who are members. Even the insured should benefit, as lower costs to the insurer should result in lower rates of increase in premiums. Preferred provider organizations themselves earn money by charging an access fee to the insurance company for the use of their network. They negotiate with providers to set fee schedules, and handle disputes between insurers and providers. PPOs can also contract with one another to strengthen their position in certain geographic areas without forming new relationships directly with providers. Contents 1 PPO 2 EPO 3 See also 4 References PPO Other features of a preferred provider organization generally include utilization review, where representatives of the insurer or administrator review the records of treatments provided to verify that they are appropriate for the condition being treated rather than largely or solely being performed to increase the amount of reimbursement due, a procedure that many providers resent as second-guessing. Another near-universal feature is a pre-certification requirement, in which scheduled non-emergency hospital admissions and, in some instances outpatient surgery as well, must have prior approval of the insurer and often undergo utilization review in advance. The rise of PPOs was cred by somewho? with a reduction in the rate of medical inflation in the U.S. in the 1990s. However, as most providers have become members of most of the major preferred provider organizations sponsored by major insurers and administrators, the competitive advantages outlined above have largely been reduced or almost entirely eliminated, and medical inflation in the U.S. is again advancing at 150-200% the rate of general inflation. Furthermore, passive PPOs are now a part of the marketplace. These PPOs obtain discounts for insurance companies on indemnity and out-of-network claims, and often take as their fee a portion of the discount obtained. The aspects of utilization review and pre-certification are now widely used even in traditional indemnity plans, and are widely regarded as being essentially permanent features of the American health care system. PPOs can also create inefficiencies and ironies in the health care industry. Though PPOs often require insurers to pay a claim within a certain timeframe in order to take the PPO discount, calculating the PPO discount and having the insurer pay the PPO's access fee is still one more step - and one more opportunity for mistakes and delays - in the already-complex process of paying for health care in the United States. Since PPOs have more power in their relationship with providers, they can still provide a benefit to insured patients. Uninsured patients may, however, be unable to obtain these discounts - even if they pay cash. EPO An exclusive provider organization EPO, is similar to a PPO, but if you seek care from a non-preferred provider you will not receive any coverage at all. Under the PPO, you would simply pay more for going to a non-preferred provider. EPOs are less common than PPOs. See also Managed care Health maintenance organization Point of service plan Independent practice association References Retrieved from http://en..org/wiki/Preferred_provider_organization Categories: Insurance | Health economics | Managed careHidden categories: Articles lacking sources from December 2007 | All articles lacking sources | Articles with specifically-marked weasel-worded phrases Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page This page was last modified on 14 June 2008, at 20:3
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