Out-Of-Network Benefits

While most PPOs these days have active participating provider networks, should the need arises to seek services from a care provider who does not belong to your PPO network, you are completely free to seek that care and still receive benefits from your PPO health insurance plan. That flexibility is one of the key benefits of belonging to a PPO. However, even though the services you receive from an out-of-network provider will be partially paid for by your PPO insurance, you will end up paying a larger share, or co-pay, of the total charges. In-network physicians have agreed to accept a lower reimbursement from your PPO in exchange for receiving more patient referrals. Out-of-network physicians are not bound by that agreement. The PPO will pay an out-of-network provider the same reimbursement it would pay an in-network provider, and the out-of-network doctor will then pass the rest of the bill on to you for payment.

While it is best to make sure you can afford the additional expense beforehand, oftentimes the peace of mind given by an important second opinion or treatment not available in your immediate community is worth the added expense.