HMO's And PPO's

[SanFranciscan]

I think the budget section is the best place to ask about health insurance since health care takes such a huge bite of out every family's budget, even those where no one is seriously ill. Teeth cleanings, corrective lenses, etc. add up fast without going into things like chemotherapy and so forth.

I used to have an HMO, which I know doctors and hospitals hate. I now have a PPO, which is supposed to be so much better. Do you think the extra expense of a PPO is worth it from the patient's perspective? Doctors may think that they are fighting for their survival just like everybody else, but I have been pretty conscientious about paying doctors. At least I have tried to be. Yet I have still gone at it with a few doctors' offices and the staff there when I have shown up for appointments thinking that I was paid up with them and had them start in on me about money. I am thinking about going back to the HMO system, where there is a straight co-payment, which patients know about ahead of time. Therefore, the patients aren't left wondering what is going on since there is never a price list in a doctor's office.

What kind of insurance do you have? What do you think of it? Have you had an HMO and a PPO? In what way did you find the PPO to be worth it, if any? I realize that a large percentage of any replies I get will come from people with financial interests in conflict with patients' best interests, but this is the budget section. That does help the odds that I will hear from patients who aren't making money off of the insurance industry.

 

[msmayor]

I have a PPO, but there is a co-payment system with it very much like an HMO. I pay a set $20 for checkups or visits to my "regular" doctor and $35 for visits to 'specialists' (dermatologist is one).

No copays for regular lab work, mammograms, x-rays...standard tests. Steep copay for CT scans and a limit of 3 per year, but these are rare.

The thing I LOVE about my PPO is that I need no referral forms at all. I get to decide when I want to see the dermatologist, an allergist, or any other specialist. As long as I use an in-network physician (and there are tons...its a Blue Cross/Blue Shiel PPO) I go by the copay schedule.

No need to see my regular doctor first for a referral, then see the specialist.

Even better is that my daughter who is away from school only needs to see any physician in the national BC/BS PPO network for coverage.

The nurses/receptionists at all the doctor's offices I visit love to see that little PPO suitcase on my health card because it actually makes life easier for them.

 

[NVDisMom]

We had an HMO years ago that we absolutely loved. We now have a PPO and it has been nothing but a nightmare. When we had the HMO we knew exactly what we had to pay before we went. We'd pay it and be done. No arguing over "Usual and Customary" charges, copay percentages or deductibles. The PPO we have now...everything is an argument. Their bill to me never matches the statement of coverage from the insurance company. We are constantly back and forth between the office and the insurer. Maybe the difference really lies in the fact that when we had the HMO we were in a small rural town and now we are in more of a metropolis...idk. As of now, if I had the option, I would go back to our HMO in a heart beat. Unfortunately, DH's company does not offer that option. We have found that we don't go to the dr unless absolutely necessary and don't pay anything until it has all been thoroughly accounted for. That is probably not best for the dr's office either, but it is the only way we can be sure to utilize our health care dollars to their best advantage. What we are missing is a personal relationship with our dr's. I miss that. Again, maybe small town vs larger metro.

 

[bumbershoot]

When I was in an HMO I never used it.

We've chosen the PPO option the last several years. I feel it's better.

The first thing I make sure to do is keep on top of the bills. We have Aetna, and you can see your account online, which is lovely. I get electronic EOBs probably 2 days after they are submitted by health care providers, so I can immediately set aside that money. I have often found myself in the position of calling offices to ask for them to send bills asap, and they are stunned that I know what my portion is already. Guess Aetna gives ME the info before the offices do.

Right now I know there's a 16.65 charge and a later 4+ dollar charge for the endo, about 130 for DS's naturopath visit, a few bucks for his strep test, and about 30 for the Aetna specialty pharmacy. Just gotta wait for the bills to arrive!

I could not deal with the nonsense of needing a gatekeeper. When hubby was diagnosed with diabetes, his joke of a family doctor ignored everything about the presentation of it all, saw NOTHING but his weight, refused to believe that his mom was skinny and was diagnosed with type 1 not 2, and refused to send him on to an endocrinologist. Forget that! We dumped the dude, got the records from the Urgent Care side of the same office, and self-referred to a specialist.

That specialist has been good for us, because he's been willing to listen to what hubby has to say (he's put up a slight fight but the results are proving us right so he's better now), and he's also willing to do tests hubby asks for. Therefore, he was finally diagnosed with a pituitary tumor that has probably been in existence for at least 3 years (by signs/symptoms that other docs have been ignoring). There's been a related issue, which has now also been taken care of, because we could self-refer without a gatekeeper.


Thankfully Aetna has a big enough network that it's easy to find acceptable people in-network. But if we couldn't find someone in network, that's OK, we know what our deductible is for that and the percentage too (though as you said, the wild card is always what they are going to charge).


The only bummer is that our plan ONLY allows us to use in network pharmacies. That's not a huge issue for hubby, but we opted for antibiotics for DS's strep. Due to our dietary decisions and DS's dietary restrictions, neither the capsule nor the liquid worked for us. So we had to go to an out of network compounding pharmacy for them to put the pill powder into non-animal-based capsules. All out of pocket. (in the future, should we need it, I'll get the prescription filled for pills at an in network pharmacy, and have the compounding people just transfer the powder to the acceptable capsules)

But for the freedom the PPO gives (relative term, of course, when it comes to insurance companies), I'll deal with that.

 

[SanFranciscan]

We had an HMO years ago that we absolutely loved. We now have a PPO and it has been nothing but a nightmare. When we had the HMO we knew exactly what we had to pay before we went. We'd pay it and be done. No arguing over "Usual and Customary" charges, copay percentages or deductibles. The PPO we have now...everything is an argument. Their bill to me never matches the statement of coverage from the insurance company. We are constantly back and forth between the office and the insurer. Maybe the difference really lies in the fact that when we had the HMO we were in a small rural town and now we are in more of a metropolis...idk. As of now, if I had the option, I would go back to our HMO in a heart beat. Unfortunately, DH's company does not offer that option. We have found that we don't go to the dr unless absolutely necessary and don't pay anything until it has all been thoroughly accounted for. That is probably not best for the dr's office either, but it is the only way we can be sure to utilize our health care dollars to their best advantage. What we are missing is a personal relationship with our dr's. I miss that. Again, maybe small town vs larger metro.

It isn't just in cities. Things have changed all over. The local community hospital used to be the blue-blood charity. Now it is the blue chip stock. My husband is old enough to remember when entire towns got involved in fundraisers for their local hospitals. I am not quite old enough to remember this, but I have heard about it. I would be much more likely to give to a hospital or a doctor's clinic in a town that I didn't even live in than to the disease research gangs that are hitting me up all over the place, including hardcore at my supermarket.

When a collection is being taken up for someone I don't even know to get treatment, I give what I can whenever I can. I have quit giving to research because I think that just goes in the fundraisers' pockets. People are already dying from lack of treatment due to insurance battles. How is more research going to change that?

Being a doctor used to be very prestigious. Now a lot of people hate doctors as much as the much-maligned lawyers are hated in this country because health care isn't about treating the patient but what they can bill insurance companies for. I don't want to pay my doctor so little that I run him or her to bankruptcy. I just don't like feeling that I am dealing with a bunch of proverbial used car salesmen when I go in worried about my or my husband's health. I have spoken to many patients who feel like going to see any doctor is buyer beware. Sad. Very sad.

 

[Chicago526]

I don't know. My HMO is great about paying for stuff, the only time I've had trouble with denials is when the docs/labs/hospital doesn't submit thing correctly, and that's easy to clear up (with one exception, see below).

But I hate that EVERYTHING has to go through your primary. My HR department screwed up when I added my DH and made it seem like I had changed my primary doc when I didn't autherize any such thing. When I had to have an outpatient surgery it was discovered, but only after I was responsible for about $1000 worth of doctors bills (HMO wouldn't back date my re-selection of my original primary even though they said they would). With a PPO, it wouldn't have mattered who I saw, it would have been covered.

DH and I decided to give the HMO another year, when things work well they really do work. But if we have any more problems, I think we'll switch.

 

[disfan07]

We never had an HMO...we have always had a PPO and my parents refuse to ever get an HMO even if it is cheaper.

With a PPO, you are free to see whoever you want (we are allowed to go out of network if need be) I can go to specialists whenever i want and I do not need referrals.

For example: My pulmonologist referred us to a cardiologist who sent me to an Electrophysiologist. We did not like that Dr, so we went to another one. Did not like him either. Went to a 3rd one within 3 weeks and absolutely loved her and now she is my permanant cardiologist.
With an HMO, we would have had to get referrals, etc. and we would have had to stay with someone we did not like b/c it would have taken too long to get to someone else.

The PPO has also given us the freedom to go to Hopkins, Duke and Cedars-Sinai without referrals.

I know a lot of people who have HMOs who have had to wait months to see a specialist even for things like seeign a dermatologist for a possible skin cancer. We like being able to see who we want when we want.

We have a $20 copay for primary and $40 copay for specialists. That's what we pay everytime. No copays for ER visits, x-rays, labs, etc.

I love every single one of my doctors (all 5 of them) and they all are associated with one of the best hospitals in the country. The care that I am getting, I would probably not get with an HMO...jmho

 

[bumbershoot]

The PPO we have now...everything is an argument. Their bill to me never matches the statement of coverage from the insurance company. We are constantly back and forth between the office and the insurer.

Have you ever had the insurance people call the office?

I once saw a doc who was a preferred provider. That means she agreed to take what the insurance gave her (along with my copay), and she was NOT allowed to ask for anything more. Well, she asked. So I called UHC (insurance at the time), they just about had a cow, put me on hold, called the doctor's office. Fixed inside of 10 minutes. Insurance companies don't like it when their preferred providers try to collect money they agreed to not collect...

 

[wmharley]

I think the budget section is the best place to ask about health insurance since health care takes such a huge bite of out every family's budget, even those where no one is seriously ill. Teeth cleanings, corrective lenses, etc. add up fast without going into things like chemotherapy and so forth.

I used to have an HMO, which I know doctors and hospitals hate. I now have a PPO, which is supposed to be so much better. Do you think the extra expense of a PPO is worth it from the patient's perspective? Doctors may think that they are fighting for their survival just like everybody else, but I have been pretty conscientious about paying doctors. At least I have tried to be. Yet I have still gone at it with a few doctors' offices and the staff there when I have shown up for appointments thinking that I was paid up with them and had them start in on me about money. I am thinking about going back to the HMO system, where there is a straight co-payment, which patients know about ahead of time. Therefore, the patients aren't left wondering what is going on since there is never a price list in a doctor's office.

What kind of insurance do you have? What do you think of it? Have you had an HMO and a PPO? In what way did you find the PPO to be worth it, if any? I realize that a large percentage of any replies I get will come from people with financial interests in conflict with patients' best interests, but this is the budget section. That does help the odds that I will hear from patients who aren't making money off of the insurance industry.

If you rarely get sick, a PPO is better for you as generally, it should be less month to month.. Or even better a high deductable HMO/PPO plan.

Our HMO acts like a PPO in that we don't need referrals to see a specialist at all. Normal visits are $15 and specialists are $25. My doctor is on the preferred list, so what he says, goes, no authorization needed. I needed an MRI on my neck, and because he requested it, there was no hassle by the insurance.. they immediately approved it.

We had a PPO with our DD when she was born.. spent over $3000 for that labor/pregnancy... spend $300 for DS on the HMO ($200 for the labor and $100 for something else)..

IF you have an HMO where you need to get approval for everything, then its knda crappy.. but our HMO is great...

I want to keep it, but with the idiocy of Congress now, its doubtful I'll have it in a yr or 2.

 

[squirrlygirl]

We're switching to a PPO next year from an HMO. The HMO had limits on many things, and we ended up paying out of pocket for services when we reached the limits. DD had eye surgery in January-and we got a bill for half the physician's fees. A disclaimer in a section of the benefits booklet not finalized until May mentioned that certain surgeries would only get half paid, plus we pay the deductible. They just stuck "even when medically necessary" after everything they limited. Also, only 1/2 the specialists and hospitals in this area accepted the HMO.

We are paying extra per month for the PPO, but we'll also have better coverage and access. Consider our out-of-pocket costs with the HMO, and it will be cheaper. I know we'll fight over EOB's with the PPO sometimes, but DH's employer has an advocate that will take up the fight for us if needed.

 

[dioxide45]

With a PPO you have to be much more conscious of the coinsurance amount (is it 80/20 or 90/10). Many HMOs pay 100% after the copay. PPOs tend to fall in to the 80/20 coinsurance, meaning you pay 20% of the costs after the copay and the insurance company covers 80%. So even after you leave the doctors office you will be getting a bill.

It is also important that with a PPO that you still try to stay in the network of contracted providers. If you go to a provider out of the network the insurance may only cover 60%. Also, they may only cover 60% of usual, customary, and reasonable charges. So if your doctor bills them $300 for something that the insurance company says they should only reasonably charge $150 for, you pay 40% of that $150 plus the other $150. So you would pay $210 for that office visit. Stick to the in network doctor. If they bill $300 but are contracted with the insurance company to only get paid $150 for those services then they write off the other $150. You pay only your copay plus 20% of the $150.

Always look up providers or labs you may be referred to for follow up treatment. My wife went to an office where they took blood work right there, it was sent to an out of network lab. You need to make sure you ask who is doing the work and checking them out before going. We also went to an urgent care in Florida once. We checked them out before leaving and they were in network, well the clinic was. The doctor in that clinic who also billed for services was not. So our final bill there was ridiculous.

We have had both an HMO and PPO. We loved our HMO in the past only because it had a better option for prescriptions. Our company has changed the plans around and there is now no difference with prescription coverage, so we opt for the 80/20 PPO.

When comparing PPO plans, the coinsurance is more important to compare than the co-payment because that is where the real costs will be. You may be able to get a PPO with 90/10 coverage, you will probably pay more for it but it will control your costs better also.