Each year, more and more individuals find themselves enrolled in some type of network-based health plan. In the alphabet soup that is the health plan world of 2018, we see traditional Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Exclusive Provider Organizations (EPOs), or Point of Service (POS) health plans.The common thread among all of these types of plans is that there are-to varying degrees-financial ramifications for a patient seeking care from a provider who is not part of the health plans network. In the most extreme cases (HMO or EPO), the plan will pay nothing if the enrollee seeks care from a non-network provider, unless it is an emergency. In the PPO or POS models, patient care provided by an out-of-network provider will be covered by the plan but typically with a higher beneficiary co-insurance or co-pay. In almost all instances, receiving care from an out-of-network provider will also expose the patient to paying the difference between what the health plan may have paid and the full charge by the provider (ie, balanced billing).
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