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PPO vs. HHO

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Has anyone here seen or know about PPO horror stories?

 

I searched the web for news reports on this and found mostly good reports about them instead.

 

I was surprised that even though PPOs only offer partial reimbursement for out-of-network care, that no victims have come forward on the media. This could not possibly mean that no one has ever had an outrageous medical bill when the PPO did not give adequate reimbursement.

 

I notice there are lots of complaints about HMO plans.

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First, consumers with out-of-network benefits at any level of reimbursement are not "victims." Insurance is a product and should be scrutinized with the same vigor as any other product, tangible or otherwise. Most people know more about Justin Bieber than their own insurance coverage, and Beebs doesn't cover one red cent of their healthcare expenses. Insurance terms are clear; countless state and federal regulations require this. If they are in any way unclear, they should be questioned. That is part of being a responsible and educated consumer. Believe it or not, there are insurance company representatives that can and will spend time going over every dirty detail of your plan until you can recite them backwards in Yiddish. I know because I did it for years. Except for the Yiddish part. It's very esoteric and most people don't get it.

As for complaints and/or horror stories, you could yell the question out your window and get ten eager responses. People love a good insurance screw job story, regardless of circumstances. Search again on Google and I guarantee you'll find anything you could care to see. Many will be true... and many more untrue.

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Has anyone here seen or know about PPO horror stories?

 

I searched the web for news reports on this and found mostly good reports about them instead.

 

I was surprised that even though PPOs only offer partial reimbursement for out-of-network care, that no victims have come forward on the media. This could not possibly mean that no one has ever had an outrageous medical bill when the PPO did not give adequate reimbursement.

 

I notice there are lots of complaints about HMO plans.

I'm sorry but how is a consumer who purchased a product and knowingly sought care at an out-of-network provider (knowing that there would be out-of-pocket costs) a "victim"? PPOs reimburse out-of-network providers at a set rate established by the plan. If you know your plan reimburses 50% of out-of-network providers and you seek care at an expensive provider who tells you the fee for their services is $800, you're not a victim when you get a bill for $400.

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I'm sorry but how is a consumer who purchased a product and knowingly sought care at an out-of-network provider (knowing that there would be out-of-pocket costs) a "victim"? PPOs reimburse out-of-network providers at a set rate established by the plan. If you know your plan reimburses 50% of out-of-network providers and you seek care at an expensive provider who tells you the fee for their services is $800, you're not a victim when you get a bill for $400.

Exactly. There is no victim when a consumer voluntarily chooses to see an out-of-network provider. The OON provider is not obligated to accept the contracted rate as payment in full and the patient is notified up front of this potential additional charge. If the patient chooses to sign without reading how are they a victim?

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Maybe the fact that you searched the Web and didn't find any reports is your answer. PPOs work as people here have described, and it is the responsibility of individuals to understand how their insurance coverage works. (Granted, the entire for-profit healthcare insurance system in the US stinks, but that's another conversation. This is the system we're stuck with, at least for the time being.)

I'm wondering, does this thread have any connection to your previous thread sbout high hospital bills?

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I have checked out several web reports and from what I can see, there have been clients who went to a hospital in their own network but there were practitioners working in them who were not in the network and so they "inadvertently" got out-of-network care and were sent the bill.

A report I read also says they can file an appeal when this happens. but without doing extensive research, I would not know how often this is successful.

Just because there are news reports about "heartless, bureaucratic" H.M.O.s" when one does a web search and almost no similar complaints about P.P.O.s I would not want to assume that P.P.O.s are always good.

I was looking for feedback from people whose patients might have had to fight with the insurance company even when it was supposed to reimburse them.

I was also wondering how many clients end up with an outrageous bill even when the insurance company did pay like it was supposed to.

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Maybe the fact that you searched the Web and didn't find any reports is your answer. PPOs work as people here have described,

I'm wondering, does this thread have any connection to your previous thread sbout high hospital bills?

To answer the question, you're right and this thread is connected to my other one. I might be back again with more insurance and billing type questions since this is an unfamiliar topic for me and I'm trying to tap into as many sources of information as possible.

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Sometimes customers of a PPO are referred to or require the expertise of a health professional or facility that is out of network for their insurance.

In my experience, there are specific things that are required by the insured which, when completed appropriately and in a timely fashion, result in adequate coverage by the PPO to avoid financial devastation. For instance, a person something like lung transplant may not be able to obtain that through their local participating hospital. However, with appropriate referral and appropriateness of care documentation and communication with the insurer, arrangements are often made to the overall satisfaction of all involved.

My cousin in Michigan lived in a community which did not provide Pediatric Cardiac surgery in the local participating hospital for her PPO. When her newborn required that service she secured the coverage with a phone call and a properly executed referral from the child's participating provider. That actually happened very quickly while the child was being triaged and transported.

I am sorry that you have had difficulty with insurance payment. Historically, medical bankruptcy has accounted for 60% or more of all bankruptcies in the USA. Not all of those people were uninsured, unfortunately. In fact, some data reflects that 3/4 of those individuals did have health insurance.

Good luck.

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