Do you ever wonder why you get an
out-of-network denial by an insurance that you participate with?
With so many plans out there it’s difficult to keep track of them all, and to understand whether your patient’s care is covered. It may be that you are enrolled with the PPO but not the EPO, or the HMO and not the PPO, etc.
What is an HMO?
An HMO is a Health Maintenance Organization.
It is an organization of providers that are available within a plan and are dedicated to the member’s care.
This is referred to as the network.
With an HMO, a patient must choose a primary care physician and obtain a referral for any specialty care.
HMO’s were created as a means to reduce healthcare costs and decrease unnecessary paperwork, and will not provide coverage for any care received outside the network.
What is a PPO?
A PPO is a Preferred Provider Organization.
PPO’s are slightly more flexible, allowing a patient to choose to see any provider whether they are in the network or not, with no referral required.
Typically, the cost sharing is higher for out of network care and not all care is guaranteed to be covered.
What is an EPO?
An EPO is similar to an HMO.
An Exclusive Provider Organization, it allows patients to see specialist without a referral, and there is no requirement to choose a PCP, but the network of participating
providers is limited.
And, an EPO will not cover care outside the network at all.
What can you do?
When enrolling with a health care plan as a participating provider, be sure to inquire about all the plans available. Decide whether you will enroll with all plans, or
just certain ones.
Be aware of the reimbursements rates and how they vary if you do decide to remain out of network, and be sure to know whether you will reimbursed at all.
And keep an open line of communication with your patients.
Encourage them to get involved and keep themselves educated regarding what types of coverage they have.
Be open about out-of-network care that may not be covered right up front, and be sure you patient is aware that they may be responsible for full payment of any non covered care.
What should your patient do?
Your patient should be verifying you are in network before calling for an appointment, but to protect yourself, always verify your network participation with a patient’s plan before seeing the patient to avoid surprises and missed revenue.