Ask Colleen King - Blogs

Blogs - Comment(s)


But I have a PPO--what do you mean I have a PCP now?

11-02-2016 by Colleen King

One of the main reasons people tend to like PPOs, unless they've had a good HMO experience, is the freedom to choose which doctors they go to. You can see someone contracted with your health plan, or not. If they aren't contracted, you pay more of the cost. And there is no 'discounted,' contracted rate to help contain your costs.

So when Covered CA came out this year and dictated that even if you have a PPO you will be assigned to a primary care provider (PCP) agents were very alarmed, because we knew the phone would start ringing. No, you still have a PPO, you just have a PCP to go with it. Here are the points, good, bad or indifferent, that you need to know about this new thing for 2017:

  • You will automatically be assigned to a PCP. Maybe it's someone you know, maybe not. The carriers are saying they may review claim info to try to assign you to someone that you've been using.
  • You don't have to use that doctor EVER--the theory is, maybe there will be a higher utilization of preventive services if a member has someone to go to, since a lot of people don't have a regular doctor. If you want to change your assigned PCP, just like with an HMO, you can at any time.
  • You can still go to anyone you want, you don't need a referral for a specialist--BIG difference from an HMO PCP.
  • This doctor supposedly is NOT being paid to be your PCP. With HMOs your PCP is paid 'capitation'--$X amount per member, per month, whether they see you or not. So the new PPO PCP, they will be compensated like they are now, when they see a patient.

So, is this going to make a difference, will it increase the use of preventive services? Dunno. Is it going to improve the quality of care? Maybe. Are patients and doctors going to like this? Remains to be seen. Just another change in our health care system that supposedly wasn't going to change once the ACA hit. So stay tuned....



Share



Leave A Comment



0 Response(s) so far


No Record Found