There are 5 types of patient plans which are offered by insurances. PPO, or Preferred Provider Organization; HMO, or Health Maintenance Organization; EPO, Exclusive Provider Organization; HDHP, or High-Deductible Health Plan; and finally POS, or Point of Sale.
Let’s quickly explore them and then let’s take a look at the billing perspective.
PPO (Preferred Provider Organization)
It is a plan which most of the people would like to have because this gives flexibility of not having to obtain any prior authorization (except for expenses services like MRI) and no need to have any assigned PCP or Primary Care Physician. A patient does not need to have provider enrolled in his/her plan. Any in-network or out-of-network provider can be consulted and insurance will pay for the services rendered. But such plans have higher premiums and their out-of-pocket costs are also high.
HMO (Health Maintenance Organization)
With slightly higher Deductible as compared to PPO plans but still lower than HDHP plans, HMO has some restrictions for its holder. A patient can only see his selected PCP or Primary Care Physician and he/she must also seek authorization for referrals. So such a patient cannot visit just any provider. So what if you see any such patient? Some practices generally write such claims off while others bill patient.
HDHP (High-Deductible Health Plan)
Such plans are suitable for healthy and young people because premiums are low but out-of-pocket expenses are higher comparatively. So if a patient visits you a lot with this plan then he may have to pay higher amounts to your practice in the form of deductibles and coinsurances. But in terms of PCP choice or authorization related to referrals, arrangement of such plans may vary depending on the choice of the member.
POS (Point Of Sale)
It is very less common nowadays. It is highly flexible because it gives patients flexibility of choosing his/her plan at the point of sale or in simple words right at the time of seeing the provider. Patient, as per his/her need can choose between HMO and PPO plan. So if, let’s say, patients wants to see a therapist or skin specialist then he/she may opt into PPO because that gives them flexibility of seeing any good specialist anytime.
EPO (Exclusive Provider Organization)
Exclusive Provider Organization, or EPO, are types of plans that do not require patient to select or have a PCP but they do require the PCP to be in-network with patient’s plan. So if PCP is not in network as per patient’s plans then provider may decide whether to write such claims off or bill them to patient. If bill amount is high them instead of billing the patient, availing Enrollment services of MED XS for enrolling with patient plan can maximize the chances of bill payment from insurance as generally speaking, patients pay less attention to bills.