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The Difference between Health Maintenance Organizations and Preferred Provider Organizations

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published August 06, 2007

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<< Health maintenance organizations (HMOs) and preferred provider organizations (PPOs) are two forms of managed care.

Health Maintenance Organizations (HMOs)

An HMO is a health service provider offering prepaid health insurance plans. In exchange for a premium paid on a monthly basis, services covered include doctors' visits, emergency care, hospital stays, checkups, lab tests, x-rays, therapy, and surgery. The insurance company controls the comprehensive healthcare provided to the insured.

The HMO employs and contracts with doctors, hospitals, and other providers of healthcare services to those it insures. The insured makes a co-payment for each visit to the doctor or hospital. The care in an HMO follows a set of predetermined guidelines with an emphasis on preventive care. This arrangement is beneficial to all stakeholders, as services are provided at a discount; the provider receives more patients, and the beneficiary pays a lower monthly premium.

Each member of an HMO is assigned a primary care physician (PCP) who is responsible for his or her overall healthcare. The PCP acts as a gatekeeper for the healthcare services utilized by the beneficiary.
  • Specialty services require specific referrals from PCPs to specialists.
     
  • PCP authorization is required for non-emergency hospital admissions.
The services of a provider not contracted by the HMO or not specifically approved by the HMO are excluded from coverage.

HMOs do not require the insured to fill out claim forms to receive benefits under their insurance plans.

Preferred Provider Organizations (PPOs)

PPOs also provide health insurance, but unlike HMOs, which employ or contract providers, they have preferred provider networks.

PPOs provide incentives like reduced costs, lower deductibles, and lower co-payments for using the organizations in their networks. Network providers agree to negotiated fees in exchange for preferred provider status because it brings them more business. The PPO, in return, promises convenience, lower administrative expenses, and timely payment as the case may be.

PPO health insurance plans have features like deductibles and coinsurance. When a beneficiary uses the services of providers, he or she first must meet the deductible and the coinsurance portion before benefits from the insurer can be paid. PPO health insurance is often the least expensive in terms of the premium paid.

As in an HMO, a beneficiary in a PPO has a primary physician within the network who handles referrals to specialists covered by the PPO. In some plans, after each visit, the policyholder must submit a claim, and he or she will be reimbursed after deducting the co-payment.

Some PPOs offer more flexibility by allowing visits to out-of-network professionals at higher charges.
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  6. The Difference between Health Maintenance Organizations and Preferred Provider Organizations

published August 06, 2007

( 14 votes, average: 4.3 out of 5)
What do you think about this article? Rate it using the stars above and let us know what you think in the comments below.

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