Preferred Provider Organization (PPO) and Exclusive Provider Organization (EPO)

PPO’s are groups of hospitals and/or physicians who create contractual agreements with payers to offer a specified set of health care services under pre-determined financial arrangements.

EPO’s are like PPO’s in their purpose, though EPO’s limit their recipients to participating providers for their health services.

PPO’s offer EPO’s to customers in order to increase the control of health care costs.

Customers with PPO health insurance plans are able to utilize in-network or out-of-network providers, though they will have larger co-payments, deductibles, and coinsurance charges for utilizing an out-of network provider.

The fundamental Characteristics of a PPO/EPO are the following:

1. PPO’s/EPO’s often contract with selected providers in a community to offer health services for insured individuals.  They contract directly with hospitals and physicians.  Providers are chosen to participate due to their efficiency, reputation and services.

2. Participating providers of PPO’s/EPO’s are required to accept the attempt of the PPO/EPO to negotiate payment rates.  This provides the PPO/EPO with a competitive cost advantage.  These negotiated rates are typically in the form of discounts or payments based on diagnosis-related groups.

3. Some PPO’s/EPO’s include quick payment features within the contracts of participating providers in exchange for reduced payment rates.

4. Utilization Management programs are often implemented to control the cost of health services offered to covered recipients.

There are many PPO Health Insurance Plans available throughout the state of Wisconsin.  United HealthCare, Anthem BC/BS (Blue Cross / Blue Shield), Humana and WPS are some of the largest PPO’s offering health insurance in Wisconsin.  To obtain a free no obligation health insurance quote, please visit our website www.badgeralandhealth.com

 

 

 

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