comparison of HMO, PPO, POS, EPO

Dec 28, 2010 | Medical billing basics

HMO:
  1. Need a referral from PCP to see a specialist.
  2. Need to select a PCP with in network
  3. Low premium
  4. Dose not covered the out of network service
PPO:
  1. Don’t need a referral from PCP to see a specialist.
  2. Don’t necessary have to choose a PCP
  3. High premium
  4. dose cover the out of network
POS:
    1. Need to choose a PCP with in network
    2. PCP may make referral outside the network
    3. co-payments are low & there is no deductible for in network service
    4. Co-payments and deductible are high for non-network
EPO:
      1. Need to select a PCP with in network
      2. Premiums amount is cheaper then HMOs and PPOs.
      3. Need a referral from PCP to see a specialist
      4. EPOs allows partial reimbursement out of network in emergency case.
      5. This plan is combination of HMO and PPO 

PREFERRED PROVIDER ORGANIZATION (PPO)

PPO is made up of group of providers who have simply agreed to discount their services for a specific insurance plan; this provider group is generally much larger than the network in an HMO and POS.

With PPO’s, a PCP or even the group of providers does not manage a patient’s care; a patient can see any physician he wants to among the providers offering discounts. Out of all managed care plans, PPO’s give patient the most choice of providers and so they are the most expensive plans. Also, patients are not required to visit a PCP before visiting a specialty care physician.

POINT OF SERVICE (POS)

In POS, patients have the option of using in-network providers or out-of-network providers. A POS plan will reimburse services received from in-network providers at a higher rate than out-of-network providers.

If the patient remains in-network, the patient must still use a PCP to coordinate care; patient who seeks out-of-network care does not need to go through a PCP. Claim received from the out-of-network providers may be rejected or paid at a lower rate. Also the patient responsibility on a bill would be higher if he goes out of network.

HEALTH MAINTENANCE ORGANIZATION (HMO)

HMO consists of a network of physicians, hospitals, and other healthcare providers that have contracted with an insurance company to manage an enrollee’s care. Services rendered by providers outside of network are not eligible for coverage.

With an HMO plan, a patient must first refer a primary care physician (PCP); the PCP then manages the patient’s care and may refer that patient to other provider if necessary. HMO’s are generally the least expensive managed care plans for enrollees because this type of plan has the most restrictions on provider choice.

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