How to Choose a PPO

Quality of Medical Care

A PPO gives you good quality medical care if:

  • You get the right care at the right time.
  • Medical problems are found early when they can be treated best.
  • You get the treatment that has been proven to work.
  • Doctors listen to your concerns and explain your treatment choices clearly.

A PPO gives you poor quality medical care if:

  • You cannot get the treatment you need.
  • Diseases like cancer are not found early when you have a better chance of recovery.
  • The PPO delays care and a minor problem becomes a big one.
  • You are not taught what you need to do to stay healthy.

Quality of Service

A PPO gives you good quality of service if:

  • You get care right away when you are ill or have an urgent need.
  • You get answers to your questions quickly and courteously.
  • You and each family member has a personal doctor whom you trust and who listens to your concerns.
  • The materials your PPO sends you clearly explain what services it pays for and what rules you have to follow to get services.

A PPO gives you poor quality service if:

  • It is hard to find a personal doctor you like.
  • You are surprised to get a bill for medical services that you thought was paid for by the PPO.
  • It is difficult and takes a lot of time to see a specialist or get the care you need.

Choosing a Doctor

Most PPOs do not require members to choose a personal doctor -- a Primary Care Physician. The member can schedule a visit with any doctor in the PPO network without the need to get an “ok” or a referral. Though many PPO members prefer to use a regular personal doctor like a family practice or internal medicine physician, other PPO members get regular care from a specialist like a cardiologist or gynecologist and use that doctor as their main physician.

A good PPO checks the quality of its doctors. Ask the PPO what steps it takes to make sure that its doctors give good care and service.

Can I Keep My Doctor if I Change Health Plans?

If you are changing health plans and you want to keep your personal doctor, call your new plan. They will tell you if your current doctor is part of their network. If your doctor does not belong to the PPO plan that you are joining, you would have to change doctors or pay a larger share of the cost for care from your doctor. Check your PPO insurance coverage to see how much you pay for using doctors or hospitals that do not belong to the PPO.

Many doctors belong to more than one PPO. If your doctor is not part of PPO that you are considering, see if you could continue seeing your doctor by joining a different health plan.

Costs to You

PPOs offer many different insurance products—the medical services that are included and the amount that you pay can differ a lot depending upon the PPO insurance product.

All PPOs charge a monthly fee, called a premium, for the insurance plan. For working people, typically the employer and the employee share this premium cost; often the employee’s share of the cost is deducted from their paycheck. Self-employed people and others who buy the PPO insurance directly pay the full premium cost.

Your costs can differ a lot depending upon the PPO insurance product – one way that these health plans control costs is to require the member to pay a larger share of the provider’s fee for the medical service. PPOs charge members a co-payment (co-pay) or co-insurance each time they get health care services. A co-pay is a fixed fee for a specific service such as $20.00 for an office visit. Co-insurance is a percentage of the cost of the service, such as 20 percent of the cost of an office visit. One PPO product may have a higher co-pay or co-insurance for the same service than another PPO product – and, these different products can be offered by the same insurance company or by competing companies.

Your costs in a PPO often include a yearly deductible. The deductible is the amount a person pays each year before the PPO begins to pay any part of the cost of services.

A PPO contracts with doctors and hospitals using a fee schedule – to set a price for each service like an office visit, a surgery or a hospital stay. PPO providers agree to these prices and cannot charge the PPO member more. PPO members spend less when using a doctor or hospital that belongs to the PPO:

  • The PPO pays a greater share of the cost, and the member pays less, for services provided by a PPO provider. If a PPO member uses a doctor or hospital that is not part of the PPO the member pays more of the cost.
  • A provider who is not part of the PPO network is not limited by a fee schedule and can set the price for their services. The PPO does not pay more than its fee schedule amount so the member pays more if using a doctor or hospital that is not part of the PPO.