PPO stands for Preferred Provider Organization and is a network of health care providers. Insurance companies form these in order to control the costs of health care.
PPO is a network of physicians that have agreed, by contract, to discount their rates for the respective PPO members. These physicians, specialists are known as preferred providers, and PPO members are free to see any of them, without any reference from their primary physicians.
PPO members may also see non-contracted providers, these are known as non preferred providers. The co-payment fee for seeing a non preferred provider is generally higher than the preferred providers.
The following are the main advantages of having a PPO network
- The co-insurance component which is an additional expense to the customer is reduced when using services within the PPO network. For example, the Atlas America plan waives the co-insurance within the PPO network while the Patriot America plan reduces the co-insurance to 10% within PPO network. The PPO network is usually 20% up to the first $5000/- expense.
- The customer can have the billing done directly within PPO network, while it is usually reimbursed outside the PPO network.
- Providers within the PPO network have a negotiated rate with the insurance companies, and hence bills incurred within PPO network can be lower than bills outside the PPO network for the same service.
Since the policies are for sudden illness and accident, they can be used at any health care provider. Do be careful as some illnesses may not be covered if they are pre-existing or specifically excluded in the policy (maternity and HIV, for example, are typically excluded medical conditions). Most insurance companies have a PPO network that they work with and some will give you benefits (like a reduced coinsurance payment). If you visit a doctor/hospital within the provider network, the fee will be a standard rate that has been agreed between the insurance company and the provider. However, if you visit a provider outside of the insurance companies provider network, there may be a difference between the amount charged to you and the amount the insurance company considers reasonable. In that event, you will have to pay the difference between the two. You can find the links to the PPO networks in many places on our website..
Liaison Economy insurance has a PPO network of doctors and hospital in your region. To locate a provider within your area find link below:
If you are not sick, routine physical exam is not covered as it is one of the exclusions from the brochure. (Routine physicals, inoculations, or other examinations where there are no objective indications or impairment in normal health.)
If you get sick and your doctor requires you to have some blood test done for example, then it will be covered.
You can get this information by calling the toll free number of the insurance company or by visiting the insurance company web site. The toll free number should be on the insurance card that you receive on purchasing the insurance plan. If you are searching for a particular doctor, the website will likely be easier for you. Also, you can search for local hospitals to see which ones are in the network so that, in the event of an emergency, and if you are given an option, you can use those within the network. Please remember that you are never required to use a particular doctor or hospital to get your expenses covered.
Most of the insurance policies require pre-certification in the event of hospitalization, surgery or other major expense (like an MRI). Pre-certification is essentially permission that you need to get from the insurance administrator before undergoing any treatment or surgery. Pre certification is one way for the insurance provider to control frivolous or unnecessary medical expenses.
What happens if the insured does not get pre-certification before or soon after a medical procedure? In this situation, some insurance administrators penalize customers with a deductible. Other companies reduce the benefit by a certain percentage, say 50 percent. It is therefore strongly recommended that you get pre-certification for any medical treatments. When in doubt, call and get the pre-certification.
Along with hospitalization and surgery, some insurance administrators ask for pre-certification even for outpatient procedures. It is recommended that customers read the insurance document carefully before purchasing the insurance plan. Ensure that your representative, doctor or hospital informs the insurance company with details of any medical procedure being done. Insurance companies may ask for specific medical procedure codes to determine if the treatment is covered in the insurance plan.
Pre-certification has to be obtained prior to the procedure, however in the event of emergencies, approval for a treatment can be done 48 hours after the procedure. Pre-certification does not guarantee the approval of benefits and other guidelines indicated in the policy document will also be used while settling the claim.
On purchasing insurance from an American insurance plan, you will receive an insurance card with details about your policy. When you visit the doctor/hospital, the billing department will usually make a photo-copy of your insurance card, call the insurance company to verify your benefits, and then bill the insurance company directly. You will still be responsible for the deductible amount and any co-insurance that applies.
In some instances, if the medical office has not dealt with this particular insurance company, they might insist that you pay the bill on receiving medical treatment. In this scenario, you must get an detailed bill which you submit to the insurance company along with a claims form (available for download from our website) for reimbursement. American Visitor's Insurance advises policy holders to visit hospitals within the provider network wherever possible. In some cases visiting hospitals/Doctors within the PPO network will reduce the co-insurance to be paid by the patient. Also, it is prudent to keep copies of all documents you submit to the insurance company for your own records.