Monday, May 24, 2010

WHAT IS PPO AND POS

PPO (preferred provider organization)

This plan is somewhat similar to indemnity plans. It offers you the freedom to access the doctor of your choice. (Costs are lowered within a given network however) If you travel outside the network, you will be forced to pay a copayment based on higher charges. In addition, you might also be forced to pay the difference between the fee and the amount covered by your specific health insurance plan.

POS (point-of-service)

A POS health insurance plan is one of the more expensive insurance plans to choose from. Within a POS health insurance plan, you have a primary care physician (PCP) who has the ability to refer you to other providers within the given health insurance plan. If your PCP refers you to a physician outside of the network, all or most of the bill will be covered by your POS plan. Within the POS plan you also have the option to refer yourself outside of the network. However, in such instances, you would have to pay coinsurance.
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Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.


Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)


Medicare Physician Fee Schedule Payment Rates Formula


The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF

Medicare fee schedule download