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whats the difference w/HMO & PPO (health insurance & PIOG)

we are trying to find a pediatrician in our town, they accept our health insurance company but then they ask are we HMO or PPO and we are HMO, they say they do not accept HMO... i was wondering what the friggen difference was...please help!


Asked by danette624 at 2:00 PM on Sep. 29, 2009 in Just for Fun

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Answers (6)
  • Sure! HMO's plans rely on you having a PCM or primary care manager. This term may vary from plan to plan but basically it means that there is one person who decides and is in charge of and organizes your care. It means that your pediatrician (or internal medicine, family doctor, etc) is the person who would refer you for specialty care and would help you maintain your health. HMOs are usually based around preventative medicine. They are usually heavy on patient education but they often do not reimburse as well as PPOs (not your concern obviously but could still cause certain doctors to not be able to accept them- also I believe they are harder for doctors to get contracted with) PPOs do not require a referral. If you want to see an ENT- you simply go to an ENT. But HMOs often require more paperwork for pediatricians because they must make referrals and coordinate care.


    Answer by CooksWife at 2:12 PM on Sep. 29, 2009

  • with ppo you can go to any doctor. with hmo you can only go to a Dr in the hmo network. you have to get a list of doctors in your network and choose one. then if you need to see an additional dr you have to get a referral from the first dr. With ppo you do not need that.

    Answer by Anonymous at 2:06 PM on Sep. 29, 2009

  • aahhhh lol ok thanks, i actually just got done looking it up...i was getting so mad and confused lol

    Answer by danette624 at 2:09 PM on Sep. 29, 2009

  • another question lol is a family health care provider also considered a ped.? right now we dont have any of it set up, just my ob and some docs at our hosp that we will be delivering at. i was wondering because if we could just set up a family doctor for me and hubby and the doc could also do check ups on the baby that would be great!

    Answer by danette624 at 2:27 PM on Sep. 29, 2009

  • Well you would need a family doc for the adults but the ped can be the primary for your children... Or your children can be seen at a family doc with you guys. We had a DO that was a family doc with our HMO but they couldn't do vaccines in the office so I switched the kids. Each doctor (this is just on their end) has to apply for a contract to accept insurance companies. The insurance company then decides if they want to accept the doctor. That credentialing process can take a long time... Again, another reason why some docs aren't able to accept certain insurances. You, under an HMO would always have the same PCM but depending on the type of plan/location may have your OB listed as your PCM until after you deliver. You may want to ask your insurance company about that. In short: If you want your whole family at one place you will have to find a family med practice and not a ped :)


    Answer by CooksWife at 3:15 PM on Sep. 29, 2009

  • Just reread that... Yes, usually family doc will see baby but you should call and ask because some have a age limit as to how young they will see. Our first family doc here would see from birth on but some here wouldn't see peds until they were at least 6 months or a year. Sorry! I'm long winded on here sometimes lol

    Answer by CooksWife at 3:18 PM on Sep. 29, 2009