PPO Health Insurance Information:
What is PPO?
A preferred provider organization (or PPO, sometimes referred to as a participating provider organization or preferred provider
option) is a managed care organization of medical doctors, hospitals, and other health care providers who have contracted with an
insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients. A membership
allows a substantial discount below the regularly charged rates of the designated professionals partnered with the organization.
Do I have to use a PPO contracting doctor or hospital?
No, but in order to receive the highest level of benefits, members should use PPO network doctors and hospitals whenever possible.
Members can seek treatment from non-PPO doctors and hospitals; however, benefits will be at the non-PPO benefit level and will be
subject to usual and customary allowed amounts. Additionally, doctors and hospitals who are not contracted are allowed to balance
bill you for fees that exceed usual and customary amounts.
What is a PPO waiver?
A PPO waiver allows eligible charges provided by a non-PPO doctor or hospital to be reimbursed at the PPO benefit level; however,
eligible charges will be subject to usual and customary allowed amounts.
When is a PPO Waiver Appropriate?
There are two scenarios whereby a PPO Waiver might be appropriate:
A Geographic Waiver applies when there is no PPO doctor, of a particular specialty, available within 20 miles of the
subscriber's home Zip code.
A Clinical Waiver applies when a member requests to use a specific non-PPO doctor in lieu of available PPO doctor,
based on a belief that the available PPO doctors are not able to treat the particular illness in question.
"Real Life" Example Of A Case Using A Clinical Waiver:
*Names have been withheld for confidentiality
A clinical waiver is available for many plans in BCBS I have shown this to MANY of your patients that arrive at VH early.
You must do this before procedure, even if it isn't fully processed it is effective from that date. Many of the customer
service personnel "play dumb" or do not know what it is.
"Jane Doe", she was your patient in Dec2011 or Jan2012.
She is from Maine or Mass I believe. I told them about
it but it was late at night and they couldn't get it
done until - coincidentally, You called and moved her
surgery to 9 from 7. "Jane" called and insisted for
the waiver at 8 am that morning and at 10 am and much
"pushing" at BCBS received the waiver number. Otherwise
they would have had to pay the Medicare Rate less 30%
leaving them a huge bill from you.
It takes away the "out of network" status. Meaning - you get paid the highest rate for the services provided for your specialty.
If you look at PAS the Doctor, you will notice they get paid the highest rate for their services - She learned a lot about waivers by
speaking with "Ruth" at PAS. If you speak with"Ruth" at PAS she will tell you - that i have helped them get MANY of your patients paid.
They are specialists as well. Also ask "Ruth" who their favorite and most helpful patient of yours is. Not an ego boost for me, just
If you look at the 1/11/12 you will notice it was paid at the higher rate for services provided. No deductions. If you look at 7/14/12
You will notice it was all paid at higher rate - She will resubmit the remainder of bill with the clinical waiver to get that pad in full.
The current waiver for you and PAS expires January 2013. At which point I reapply and get it. BCBS doesn't share this with its
customers, why? It costs them more money. I have shared this online on a number of sites. Also a waiver will not cover services
before its date.
This is a form called "continuity
of care form" :