What does PPO network mean?
PPO stands for preferred provider organization. A PPO networkd is a directory of doctors, hospitals, labs and other medical facilities (collectively called providers) that have agreed to participate in the network. Some insurance companies have their own PPO network while others use a common PPO network that various insurance companies share.
Are PPO network providers required to accept my insurance?
Yes. The PPO network is not simply a yellow pages or internet search. It lists providers that have specifically signed a contract to accept the patients from a particular PPO network. Not accepting patients that have a specific insurance that participates in a specific PPO network when the provider is participating in that PPO network is a breach of contract.
When I called a provider from the PPO network directory, they said that they will not accept the insurance or they have never heard about this insurance. Why is that?
Make sure that you provided the name of the PPO network and not the name of the insurance product, insurance company or the insurance agent/broker.
If you provided the PPO network name and if they still don't recognize it, it is most likely a clerical issue. It is possible that the staff only knows the names of one or two PPO networks that they deal with every day and not all the PPO networks that the doctor is participating in.
If a provider in the PPO network refuses to accept the insurance, what should I do?
This does not happen often. However, in case it happens to you, you have several options:
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You can pay out of your pocket and file a claim for reimbursement.
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You can contact another provider.
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You can contact us and we will contact the appropriate person in the PPO network who will contact and properly educate the provider staff. In most cases, after such interventions, providers agree to accept the insurance and bill the insurance company to avoid a breach of contract.
In some cases, a particular provider may have stopped participating in a particular PPO network without providing any notice. Even in that case, it is necessary that the PPO network becomes aware of it so that such provider can be taken off the directory.
I would like to visit a specific doctor but their name does not come up in the provider directory. Can I visit that doctor?
Yes, you can certainly visit that doctor. These plans do not require you to go only to an in-network provider. Sometimes, a group of doctors work together and only one of the doctors signed a contract with the particular PPO network but any of the doctors in that group would see the patients and charge as in-network provider. Sometimes, the doctor you want to see is really out of network. Of course, the exact situation can be figured out only when you call that doctor's office.
When I called a doctor in the PPO network, they said that they don't accept new patients. How is that possible?
Providers participating in a particular PPO network are not employees of the PPO network. Each provider runs their independent practice and decides whether to accept new patients or not. If their practice is too busy to accept new patients, that is beyond the control of the insurance company.
When I called a doctor in the PPO network, they said that the earliest available appointment is after one week. Why is that?
Each doctor makes their own schedule, which the insurance company has no control over. Just because a doctor participates in the PPO network, it does not mean they will always be available immediately. You can see another provider or wait for that provider to be available according to their schedule. Of course, please use your best judgment in selecting what kind of provider or facility is appropriate for your situation. More information at Choosing the Right Medical Provider.
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