EPO

An Exclusive Provider Organization is a managed care plan similar to a PPO but with no out-of-network coverage except in emergencies, requiring members to use only providers within the plan's network.

An Exclusive Provider Organization is a hybrid between an HMO and a PPO. Like a PPO, EPO members do not need referrals to see specialists. Like an HMO, EPO members must use in-network providers and get no coverage for out-of-network services except in emergencies. EPOs have become more popular in recent years, especially on the Affordable Care Act marketplace. They tend to have lower premiums than PPOs because the payer can negotiate better rates with providers when members are restricted to the network. For providers, EPO credentialing and participation works the same as with any other managed care product. The key distinction that affects you as a provider is that EPO members have no out-of-network benefit. If a patient has an EPO plan and you are not in their network, they will likely not come to you because they would have to pay the entire cost out of pocket. This makes EPO network participation important for patient access in markets where EPO plans have significant enrollment. Fee schedules for EPOs vary. Some payers use the same fee schedule for their EPO and PPO products. Others have a separate, sometimes lower, EPO fee schedule. Always check the specific product fee schedule before signing a participation agreement.