Q1: As a resident wanting to learn more about the PPO process, do I need referrals to see a doctor and what happens if I can't find a PPO doctor?
Our company has established a product that utilizes a Preferred Provider Organization (PPO) network to offer professional health care as needed. The principle of a PPO is to bring savings to you, the consumer, by providing a higher level of coverage (coinsurance) and reduced premiums, while directing business to providers. This benefits physicians and facilities in the PPO because they get potential patients, rather than needing to advertise to draw in business. For the insurance company, our expenses reduce, allowing us to reduce the member premiums.
Ultimately, the coverage is yours to utilize as you please. You are in the "driver's seat", steering the course of your medical care. You have the freedom to choose any medical provider in the network that is accepting new patients. You also have the ability to change medical providers to fit your need at any time. You only need go to the PPO's website address on your ID card or call them for a list of providers. Their toll-free number is also on your ID card.
When it is an Emergency or a PPO Provider is not Available
We know that sometimes no matter how hard you try, a PPO provider is not available and you will need to see an out-of-network, or nonpreferred provider. In these situations, you are still covered. In the following situations, we allow services as if performed by a PPO provider:
- Due to the emergency nature of the care
- When no preferred provider is reasonably available within the designated service area for which the policy was issued; and when a nonpreferred provider's services were pre authorized based upon the unavailability of a preferred provider
- When the insured utilizes an in-network facility and the facility-related providers are not in-network (this applies to pathologist, radiologist, anesthesiologist, physical therapist, occupational therapist, respiratory therapist, or other physical medicine provider)
- When the insured has no choice in an assistant surgeon, if the surgeon is an in-network PPO provider.
In these situations, our company will pay a claim by a nonpreferred provider at the usual or customary charge for the service at the higher, preferred benefit coinsurance level, less any patient responsibility. Furthermore, when the insured provides documentation of payments made above and beyond the allowed amount, we will apply this amount to the insured's deductible and annual out-of-pocket maximum applicable to in-network services.
Our company utilizes Fair Health, a nationally recognized vendor, to determine usual, reasonable or customary charges. Fair Health employs generally accepted industry standards and practices for determining the customary billed charge for a service that fairly and accurately reflects market rates, including geographic differences in costs. Allowances are based on sufficient claim data to constitute a representative and statistically valid sample. Such data is updated twice per year and is no more than three years old. The methodology is consistent with nationally recognized and generally accepted bundling edits and logic.
Referrals, Discharge Planning and Continuity of Care
Your plan is not an HMO, where either a designated Primary Care Provider (PCP) carefully coordinates care, or you have no coverage. You have the freedom to use whichever provider you choose. Likewise, you have more responsibility for your care. Your plan does not require referrals from one provider to another; you are free to choose from any of the providers in your PPO network.
Your PPO ("preferred") provider has a responsibility to work with you through the following necessary changes:
- Referrals to another provider, such as specialists, for second opinions, etc.
- Discharging from a hospital, setting up rehabilitation services or home health care.
- It may be that a PPO provider will separate from a PPO network, whether because of retirement, relocation, or other reason.
When that happens, the provider has a contractual responsibility to help you transition to your next provider. In addition to these protections, we are only a toll-free number away.