Discussion in 'Medical Students - MD' started by wingy, May 12, 2002.

  1. wingy

    wingy Member
    10+ Year Member

    Aug 27, 2000
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    Just wondering if anyone can tell me the difference between HMO and PPO? Is it better to have patients with HMO or PPO or neither?
  2. Just in case there's a terminology question, an HMO is a Health Maintenance Organization. It requires patients to select a PCP (Primary Care Physician) who is used as a "gatekeeper". Referrals to specialists (except yearly eye and gyn exams usually) require pre-authorization from the PCP. There is a network of physicians who accept a given plan and all medical visits must be to physicians in the network. This isn't such a big problem in large cities (such as Boston) because the vast majority of physicians are in the network of the major health plans. However, in outlying areas, it can be difficult to find doctors (especially specialists) who take the plan. Referrals to specialists who are not in the area can be considered "in network" if the treatment is not available in what is typically considered the network (eg, transplant services for patients in rural areas may require referrals to major cities).

    PPOs, Preferred Provider Organizations, function much like HMOs except that patients are free to use out of network care, albeit usually with a higher copayment. HMOs don't cover out of network care at all (except in cases of emergency). Patients do not need referrals from their PCP to see a specialist.

    As a physician, it shouldn't matter what kind of insurance your patient has. If you are a PCP, PPO patients can seek care wherever and whenever they want, so it's harder to coordinate care. But overall, they function similarly and often have similar billing rates. PPOs open up a wider network of physicians (because of allowing out of network use), but therefore typically have a smaller network than an HMO.
  3. jdaasbo

    jdaasbo Senior Member
    10+ Year Member

    Jan 7, 1999
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    actually, most PPOs reimburse health care providers (specialists and PCPs alike) at higher rates than HMOs do. I know many primary docs that have many PPO patients but will not accept HMO insurance plans. If you compare the directory of physicians for HMO and PPO plans for the same provider, you will find that the PPO directory is much thicker.

    Insurance is quite important all physicians. It is usually the first or second question asked by the people at the front desk of the docs office. In addition, often the patient's insurance dictates what clinical courses of treatment you may provide your patient. For instance, when evaluating a patient for glaucoma, many HMO and PPO insurances in my area will not pay for nerve fibre layer studies but will pay for visual field studies even though it is well established that the former test is much more sensitive in finding the early stages of the disease.

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