In the
United States
The United States of America (USA), also known as the United States (U.S.) or America, is a country primarily located in North America. It is a federal republic of 50 U.S. state, states and a federal capital district, Washington, D.C. The 48 ...
, an exclusive provider organization (EPO) is a hybrid
health insurance
Health insurance or medical insurance (also known as medical aid in South Africa) is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among ma ...
plan in which a
primary care provider
Primary care is a model of health care that supports first-contact, accessible, continuous, comprehensive, and coordinated person-focused care. It aims to optimise population health and reduce disparities across the groups by ensuring equitable ...
is not necessary, but health care providers must be seen within a predetermined network. Out-of-network care is not provided, and visits require pre-authorization. Doctors are paid as a function of care provided, as opposed to a
health maintenance organization
In the United States, a health maintenance organization (HMO) is a medical insurance group that provides health services for a fixed annual fee. It is an organization that provides or arranges managed care for health insurance, self-funded hea ...
(HMO). Also, the payment scheme is usually
fee for service, in contrast to HMOs in which the healthcare provider is paid by
capitation and receives a monthly fee, regardless of whether the patient is seen.
History
Exclusive provider plans existed as early as 1983 as a variation of preferred provider plans, which emerged in the early 1980s.
See also
*
Patient Protection and Affordable Care Act
A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health ...
*
Preferred provider organization
In U.S. health insurance, a preferred provider organization (PPO), sometimes referred to as a participating provider organization or preferred provider option, is a managed care organization of medical doctors, hospitals, and other health care p ...
References
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Health insurance in the United States