Quote:
Originally Posted by Hopeful
If I do a PPO, and go *outside* my medical group, than it is my understanding that the insurance will pay x% of $9k. But the doctor would still be expecting the $20k. So, I'd be on the hook for the remainder.
|
Hey Hopeful!
It could be that what you are being offered is some sort of hybrid HMO/PPO.
The way a classic PPO works is that the insurance company negotiates prices with as many docs and hospitals as they can in an area, bringing them all into a "network." These are the "preferred providers." What you as a patient have to pay varies based on whether you obtain services "in network" -- that is, from providers on the "preferred" list -- or "Out of network," from providers not on the list.
For example, in my PPO plan, I pay 20% of all "in-network" charges, and 40% out of network. My carrier has a massive network within the state, so this is not a problem for me. It includes all three of the big, university-based transplant centers in the state, so that's good too. But, if I want to go to Hopkins, MD Anderson, or Seattle for my transplant, I am going to bear much more of the cost burden. It pays to get a copy of the Preferred Provider List from your insurer to make sure your docs are included. It may be accessible on-line.
Now, to get to your question. Docs and facilities get to be part of the Preferred Provider Network by agreeing to accept negotiated rates for their services.
Using your example and my coverage, if the service costs $20, but the negotiated rate is $9, the the insurance company pays the in-network provider 80% x $9, or $7.20. You get billed for the remaining $1.80 of the negotiated rate -- not for $20 minus the $7.20 the insurance company paid.
Of course, until you have met your deductible for the year, you're on the hook for the whole $9 (but not $20; you get the negotiated rate). On the other hand, once you've met your out-of-pocket maximum for the year, most plans pay 100% of the charge.
If you go to an out-of-network provider, however, you could very well wind up in a situation where the provider charges $20 (if they wanted to cut rates, they would have joined the network), the insurance company pays what they think is fair (70% of $9, or $6.30, because it's out of network) and you get a bill for $20 minus $6.30, or $12.70.
If you're going with a PPO, you want to always stay in network, or things can get expensive fast. That's why you want to make sure upfront that your providers are included in the network.
Some insurers have huge networks. I'm in NC and Blue Cross Blue Shield of NC has a network that seems to include almost every doc and hospital in the state. But a small network can limit your choices. You should definitely check out the size of the network you will be dealing with.
HMOs are definitely simpler -- though their networks tend to be smaller than PPO networks.
Hope that helps . . . .
Greg