In Health Insurance in the United States, a Preferred Provider Organization ( PPO ), also sometimes referred to as a Participating Provider Organization or Preferred Provider Option, is a managed care organization of doctors, hospitals, and other healthcare providers with insurance companies or Third-party administrators come to an agreement to provide health care at a reduced cost to top insurers or administrators’ clients.
Other functions of preferred provider organizations typically include usage reviews, where a representative of the insurer or administrator reviews the treatment records provided to verify that they are appropriate for the condition being treated, rather than being performed primarily or solely to increase the number of treatments. People deserve it. Another near-universal feature is the pre-certification requirement, where scheduled (non-emergency) hospital admissions and, in some cases, outpatient surgery must be pre-approved by insurance companies, and often subject to a prior “usage review.”
Comparison with Exclusive Provider Organization (EPO)
A PPO is a health care benefit arrangement similar to the structure, management, and operation of an Exclusive Provider Organization (EPO). However, unlike EPO members, PPO members are reimbursed for using healthcare providers outside of their designated network of doctors and hospitals. However, when they use an out-of-network provider, PPO members have lower reimbursement prices, which may include higher deductibles and co-pays, lower reimbursement percentages, or a combination of these penalties. On the other hand, EPO members will not receive any reimbursement or benefit if they visit healthcare providers outside of their designated network of doctors and hospitals. Depending on the emergency, the EPO does allow for reimbursement outside the network in an emergency. Affordable Care Act.