PPO Insurance – In network vs. out of network

The term PPO means Preferred Provider Network. PPO’s are a way of providing both medical and dental insurance. Doctors and dentists have contracts with insurance companies that ensure patients receive a discounted rate for services.

A benefit brochure will indicate that if you obtain services in network you will have less out of pocket costs and if you obtain services out of network your costs will be higher. For example, an in network benefit may be 70% and an out of network benefit may be 50%. The problem is that the percentages are not associated with the same amount that the doctor or dentist will bill. Without going through the math you should know that in network coverage will be 70% of a smaller amount billed than the out of network 50%. The result is a substantially  higher bill when services are obtained out of network. In fact if you choose an out of network hospital you may have very little coverage at all and you can incur very high out of pocket costs.

Your policy deductible is also affected by in network vs out of network benefits. The amount of a bill in network will result in you meeting your deductible sooner than if the same service was provided out of network.

The responsibility to assure that a provider is in network rests with the patient. My website has a provider tab where  you can search companies provider lists. If you find the provider you are considering to be in network print and save the page for verification if needed in the future. You can also call the membership department of your insurance company which is listed on your identification card. Document the date of the call and the name of the representative. Finally, always ask a provider if they are in network. On a rare occasion there are discrepancies which need to be addressed.

If you decide to see an out of network provider discuss your out of pocket expenses before you seek treatment. Many out of network providers have reasonable fees for their office visit. If there are procedures necessary an out of network physician will usually be amenable to have their patients obtain services by an in network provider, for example imaging and blood work.

Remember, if you have a PPO it is your responsibility to verify that your doctor is in network.


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