PPO stands for Preferred Provider Organization and is today the most common provider network arrangement associated with most health insurance plans and is the least restrictive on the actions of its subscribers/members. In simplest terms the health insurance carrier negotiates a payment contract with a medical system that makes it's affiliated physicians, facilities and other providers the "in-network" providers where people who enroll in that insurance company's products will receive the highest level of benefits/coverage. Generally PPO's allow their members to directly access the health care system at any level and as long as you are using a provider who is in the PPO network the member receives the higher in-network level of benefits. This means that there is little or no gatekeeper mechanism in place that requires the member to receive a referral from their primary care physician in order to see a specialist or obtain other more complex medical services.
For the consumer to effectively use PPO health insurance they should learn how to determine who the in-network providers are for their health plan (most easily done by going online to the insurance company's web site) and to use those providers for their health care needs.
A word of caution, this is a time of rapid change and, in many cases, consolidation of physician's practices in the world of health care. As such, physicians and other health care service providers are shifting around at an unprecedented level. So, just because you remember Doctor X as being in a certain provider network from 2 or 3 years ago is no guarantee that they are in the same relationship today. It is up to the consumer in the PPO environment to make sure they are using an in-network provider and they should verify this before receiving services from a health care provider.
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For the consumer to effectively use PPO health insurance they should learn how to determine who the in-network providers are for their health plan (most easily done by going online to the insurance company's web site) and to use those providers for their health care needs.
A word of caution, this is a time of rapid change and, in many cases, consolidation of physician's practices in the world of health care. As such, physicians and other health care service providers are shifting around at an unprecedented level. So, just because you remember Doctor X as being in a certain provider network from 2 or 3 years ago is no guarantee that they are in the same relationship today. It is up to the consumer in the PPO environment to make sure they are using an in-network provider and they should verify this before receiving services from a health care provider.