Optimizing your PPO Medical Insurance:  How to get the most of your out-of-network benefits. 

.....We have been able to work with our Out-of-Network patients so that they feel comfortable with the arrangement and feel that they are actually receiving a greater benefit from their PPO insurance plan....

In 2006 12% of Orthopaedic surgeons did not participate in PPO networks.  The number is growing every year in response to unacceptable cuts in medical fees.  More and more specialists are providing medical care for patients as out-of-network providers.  In addition, the number of good Orthopaedic specialist who contract with HMOs is diminishing every year.  By not being contracted with insurance companies physicians have the liberty to pass on a substantial saving to you.

Theoretically, one of the greatest advantages of having a PPO is the option of choosing any specialist you desire and not having to go through an authorization process.  Unfortunately you are penalized for using an out-of-network physician by having to pay a substantially higher amount for the medical service.    For example, if you have a complex knee problem and you choose to see a specialist who is not in your insurances network, you may be responsible for 40% (out-of-network) instead of 10% (in-network) of the bill.  Also, after the first visit with an out-of-network physician, the insurance company may mail you a warning letter telling you that your physician is out-of-network and that you are going to be responsible for a large part of the bill.  The insurance company will do whatever it takes to keep you within the network so that they save themselves money.

At La Veta Orthopaedic Associates we want you to receive the best specialized orthopaedic care and at the same time not be penalized for it.  If we are not in your PPO network, we may be able to "honor your in-network benefit" by providing you a financial adjustment.   In essence we provide you the savings rather than the insurance company.  This arrangement has worked extremely well for our patients. 

Some physicians do require that you submit the claim to the insurance company while others still handle the paperwork as a courtesy.  In addition some physicians are able to give a discount for paying at the time of service....a discount that you do not have to extend to the insurance company.

If you have an Exclusive Provider Organization (EPO) you probably do not have any Out-of-Network benefits.  If you have Point of Service (POS) option you might be able to see out of network doctors.  If you have a Health Management Organization (HMO) than you will not have any Out-of-Network benefit.  In such a case you will have to remain with the few physicians who have contracted with the HMO.  You need to call the insurance company and become informed. 

You may contact Dr. Mora's Medical billing service PCMS (909) 971-9334 to ask about how we honor your in network benefits.   If you wish to optimize your PPO insurance please make sure you have out-of-network benefits before scheduling an appointment.  It is your responsibility to know your benefits.  We will do everything we can to make it as "painless" as possible.   Please let us know if we can help in any way.

-La Veta Orthopaedic Associates