Navigating through the Healthcare Industry ( insurance plans)

Anuj Varma — Tue, 10 Feb 2015 22:36:10 +0000

One fine day, we will all look back at these terms – PPO, HMO, EPO, Deductibles and laugh about how we had to jump through hoops to figure out which coverage to get. For now though, the waters are tricky to navigate – and one has to understand the key differences between PPOs and HMOs (and their hybrid child – the EPO)

The Biggest Surprise – Pre-Authorization

Requires Pre-authorization? – This to me, is the DECIDER question – this essentially allows insurance companies to overrule your need for services. Since I do not trust any insurance company, I like to avoid this pre-authorization – and hence prefer plans without this need. In effect, that limits me to HMOs.

What’s the Difference Between EPOs, PPOs, and HMOs?
Pays for out-of-network care?	No	Yes	No
Requires pre-authorization?	Yes	Yes	No
Requires a primary care physician who acts as a gatekeeper to access other services?	No	No	Yes
Requires referrals to see a specialist?	No	No	Yes
How are doctors paid by the health plan?	Paid only when they provide a service. More services = more $.	Paid only when they provide a service. More services = more $.	Paid the same amount each month whether they provide lots of services or none.

Note that PRE-AUTHORIZATION is different from REFERRALS – in case of referrals, PPOs are more flexible than HMOs. In case of pre-auths however, HMOs win hands down.

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Navigating through the Healthcare Industry ( insurance plans)

The Biggest Surprise – Pre-Authorization