PPO

A Preferred Provider Organization is a managed care plan that offers a network of contracted providers at lower costs to members, while still providing some coverage for out-of-network services at higher cost-sharing.

A Preferred Provider Organization is the most common type of health insurance plan in the United States. Unlike an HMO, a PPO does not require members to choose a primary care physician, does not require referrals for specialist visits, and provides some coverage for out-of-network services. For providers, PPO networks are generally easier to participate in and more straightforward than HMO networks. You see patients, submit claims, and get paid based on the negotiated fee schedule. There is less administrative overhead compared to HMOs because there are fewer prior authorization requirements and no gatekeeper referral process. PPO fee schedules are typically higher than HMO fee schedules because the plan design gives members more flexibility and costs the payer more. The payer passes some of that cost to the member through higher premiums, but the reimbursement rates to providers are usually better. PPO credentialing follows the standard process. The fact that a plan is a PPO versus an HMO does not change the credentialing requirements. You still need your licenses, certifications, CAQH profile, and all the standard documentation. The difference is more about how the plan operates after you are credentialed. Many payers offer both HMO and PPO products. When you credential with a payer, make sure you understand which products you are being enrolled in. You might be approved for their PPO network but not their HMO, or vice versa. Some payers credential you for all products simultaneously, while others require separate enrollment for each product line. Most employer-sponsored health plans are PPOs, which means being in the major PPO networks gives you access to the largest patient population. When prioritizing which payers to credential with, PPO networks are usually at the top of the list.