HMO, PPO, ABC, 123

Understanding the delivery system of health care is tough stuff. This entry is just meant to define some terms that every provider should know, but often this is not the case. As PAs will soon be practicing within these systems (or something similar)… and we should know what they are and basically how they operate.

HMO: Health Maintenance Organization

Basic Knowledge:

There are different models of HMOs (staff model, group model, and network model).

Staff models = providers are paid directly by the HMO.

Group models = the HMO pays the group and the group distributes the money to the providers.

Network models = the HMO pays providers in a network of groups

PPO: Preferred Provider Organization

Basic Knowledge:

An effort to supply health care services at a discounted cost by providing incentives for patients to staying “in-network,” but which also provides coverage for services rendered by “out of network” providers but at a higher cost.  

Hope this helps. Any questions? Feel free to ask. Knowledge is power. 

Information gathered from a lecture by Paul Gardent, MBA, CPA (The Dartmouth Institute)