Written by: Mitch Bruce, Patient Account Manager, Wickenburg Community Hospital
Insurance is CONFUSING! Medical insurance is no exception. To make things worse agents start tossing around terms like in network, HMO, and pre-auth, it’s no wonder we have difficulty understanding what we’re really paying for.
Here at Wickenburg Community Hospital we are asked a lot of questions about health insurance and how it works. By understanding some of the key terms, you will find navigating through your plan a little easier.
PCP = Primary Care Provider, some plans require that you choose a PCP. If you have a PCP listed on your insurance card this is the provider you must see for your regular care.
PPO = Preferred Provider Organization, these are providers that are part of your insurances network so claims will be processed as “in network” for maximum benefits.
HMO = Health Maintenance Organization, this is a network of providers to include specialists that are part of your insurances network that is usually local and very small. This requires that you choose a PCP and all care must be routed through that provider. It also requires referrals to Specialists.
IN NETWORK PROVIDER = this is a provider that is contracted with your insurance to see patient within a specific network. This usually means less out of pocket cost for patients.
OUT OF NETWORK PROVIDERS = this means that this provider is not contracted with your specific network even though they may take your insurance. This usually means a higher out of pocket cost for the patient.
OUT OF POCKET = the amount the patient has to pay for a service. This is determined by the insurance company.
Hopefully, these explanations help to clear up some insurance confusion. If you have a specific question please give our business office a call as we are happy to help! 928-684-4365