What is a PPO
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What is a PPO?

PPO stands for Preferred Provider Organization. A PPO is a kind of health insurance or managed care plan.  


PPO basics

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.