Avoid the Hassle.
Clients often choose a MAPD PPO plan because they believe such a plan has no “Hassle Factor”. They are often mistaken. The following “Hassle Factors” examples are taken from one health plan’s Evidence of Coverage (EOC).
Some In-Network services do require prior authorization from the plan in order to be covered. Obtaining prior authorization is the responsibility of the Primary Care Physician or treating provider.
When you read the actual Evidence of Coverage (EOC) you will find a significant number of In-Network medical services require prior authorization. The plan can deny the service. Even when approved, there may be a delay factor before the service can be obtained.
You don’t need to get a referral or prior authorization when you get care from out-of-network providers.
HOWEVER, if it’s later determined that the services are not covered or were not medically necessary, coverage may be denied, and you will be responsible for the entire cost.
If the Out of Network provider does not accept assignment, they can charge you up to 15% over the Medicare-approved amount. The Out of Network provider may also require the patient to pay directly to the practice and submit a reimbursement claim to their health plan.
Also, when selecting a PPO make sure that your doctors are IN-NETWORK providers. While freedom of choice to Out of Network care is an attractive benefit, it can be costly. PPO Out-of-Network “Maximum Out-of-Pocket” (MOOP) expenses can be as high as $10,000 per year and Co-pays and Co-Insurance will always be higher when using Out of Network providers.
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