Whenever I speak to an Individual or Employee about their Health Insurance choice, they tell me they want a PPO Health Insurance Plan so they can go to any doctor or hospital they want! Hold your horses! A PPO plan is not what you think! PPO stands for Preferred Provider Organization because there is a list (network) of healthcare providers that the Insurance carrier prefers you to use. In-network doctors have agreed to accept the contracted rate of the Insurer for medical services provided. If you get your health care from one of these providers, you will pay less. If you use an out-of-network provider there is no limit to what you might pay out of pocket. An out-of-network provider is not required to honor the contracted amounts set by the Insurance carrier. The Insurance carrier will only “reimburse” you for the contracted amounts.
There are multiple networks with every Insurance Carrier and not all networks are created equal. For instance, the cost of an insurance plan is in direct proportion to the number of doctors that are contracted with the network. A Bronze Plan with Health Net could cost 70% less than a Bronze Plan with Blue Shield of California simply because there are so few doctors contracted with the Health Net Plan. In the big picture, the more physician options you have, the more likely you are to find a doctor to treat you and the more valuable your insurance is.
PPO Plans allow you to self-refer. This means you can go straight to the Cardiologist of your choice without going through a lengthy referral process. But usually, a Specialist will want to know if your doctor made a recommendation to see a Specialist. The Specialist will ask for the results of all the tests your Primary Care Physician already processed that suggest you need specialty level care. In other words, they want to know that you’re not self-diagnosing before taking you on as a new patient. Getting a recommendation for a Specialist from your doctor is great. But your family physician doesn’t know if that Specialist is contracted with your Insurer’s network. It’s the patient’s responsibility to check with their Insurance Carrier before making the first appointment.
Health Insurance is tricky (what an understatement)! If you have questions about your Health Insurance, talk to your Broker or the Broker who sold your Employer the group policy. Or call Jami McNees – The Health Insurance Lady #0H98382 951.265.2784 or Sam McNees– The Health Insurance Guy #4068040 951.972.2099.