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What is an Exclusive Provider Organization?

Edward Neeman | Published: June 14, 2018

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Updated: December 27, 2017

Health insurance is such a confusing industry, and it seems like there's a new term that you've never heard of popping up each week. Whether you are new to the world of healthcare, or a seasoned veteran, you may never have heard of an Exclusive Provider Organization or its shorthand EPO. Find out why so many people are considering EPO health plans rather than the traditional PPO and HMO plans.

What is an EPO Plan?

An Exclusive Provider Organization, or EPO, is a network plan of medical providers, either individuals or groups, who are in written agreements with an insurer to provide health insurance to its members. As a subscriber, you cannot outsource healthcare services from another plan and only use the medical doctors and hospitals within your given network. Exclusive Provider Organizations have a mutually benefiting relationship with health insurance companies in that, the network of health care providers provide services to subscribers of the plan who are later reimbursed by the insurers. The medical services are offered at a relatively lower price than other general medical services. The healthcare providers then get business by having a constant inflow of patients who are subscribers of the plan.

In some instances, an Exclusive Provider Organization can link up with another EPO to increase their overall business performance and have a competitive advantage in their geographical area. Facilities and personnel within the Exclusive Provider Organization are medical professionals, laboratories, hospitals, and clinics.

When you set out to choose a health insurance plan that best fits you, it is recommended that you know what is offered by HMO, PPO, and EMO and how to differentiate them.

What is an HMO Plan?

This is an abbreviation for Health Maintenance Organization. In this plan, you are required to pick one primary physician for all your services and would, therefore, need a referral if you wanted to see another physician with the exemption of an emergency. The referral cannot be authorized unless the guidelines find it fit. For instance, if you have a toothache, you wouldn't go straight to a dentist but your primary care physician. If they can’t assist you, they will give you a referral to a dentist because the HMO guidelines then permit it. The only exemption is for cases concerning obstetricians or gynecologist cases that require routine checkups for women.

HMOs, however, do not cover costly diagnosis, treatment, elective plastic surgery and mental health care is limited. It, however, does cover preventive care to prevent members from acquiring preventable conditions that would end up being costly. HMOs are cost friendly and involve less paperwork as all your health care activities are handled by one primary care physician.

What is a PPO Plan?

PPO stands for Preferred Provider Organization. This is also a subscription-based medical car agreement plan. This plan is more flexible, as you have the freedom to visit any medical professional you prefer without a referral within and out of your network. PPOs earn money by charging health insurance companies for use of their network. Its subscribers, however, pay higher premiums than HMOs.

EPO vs. HMO vs. PPO 

An Exclusive Provider Organization combines the flexibility of PPOs as a primary care provider is not needed and has a network of medical care provider. The plan also charges an access fee to the health insurance companies for using its plan like in PPOs. It is also cost-friendly like HMOs, EPO 's use a fee for service payment scheme unlike in HMOs. The healthcare provider, therefore, receives payment monthly without putting into consideration whether they see a patient or not. Exclusive Provider Organizations don’t cover care outside of the network plan of healthcare providers unless it’s an emergency like child delivery or trauma accident.

Exclusive Provider Organization plans are best recommended for their advantageous package over other plans. When choosing an Exclusive Provider Organization plan from health insurance companies, it is important to compare and contrast the various health insurance quotes offered. This shopping around for health insurance quotes guarantees a good feeling one you are subscribed to a plan as you know that you have got the best deal that is out there.

When scouting for health insurance quotes, here are a few key pointers to follow:

  • Visit online sites to compare the quotes offered and scout for good prices before physically visiting the organizations.
  • For every quote, look for the services entailed and the range of insurance products that are offered.
  • Talk to insurance agents to get advice on the best deals from the various service providers.
  • Ask your friends and workmates for recommendations and referrals to know what to go for and what to avoid.
  • Talk to company representatives to gain an insight on the offers that are there and the representatives are customer oriented so they would have your best interests at heart.
  • Consult with healthcare providers on the best deals available as they work directly with most insurance companies and would, therefore, be better placed to give recommendations.

Do not settle until you get the best deal. Health is of vital importance in your life and that of your loved ones and for that matter, you deserve the best health insurance plans. Are you ready to stop gambling and get the best health insurance plans with favorable health insurance quotes? Start your search with First Quote Health, and get some peace of mind.