Exclusive Provider Organization (EPO)

Any individual that requires access to healthcare insurance can select from a wide range of available insurance plans. All these plans must comply with the ACA to provide healthcare to citizens as stipulated by the law. Exclusive Provider Organizations is an example of one such insurance plan.

Definition of EPO

The EPO is described as a custom healthcare insurance plan that provides healthcare insurance coverage to individuals from a list of exclusive healthcare providers contracted explicitly by the insurer to provide healthcare services to its clients. EPO is quite similar to HMO and PPO in that individuals must stick to accredited healthcare providers.

Healthcare insurance holders stand the chance of not getting their claims paid by their insurer if they get healthcare services from non-accredited facilities. EPO usually provide low cost-sharing than many other plans.

Additionally, the EPO healthcare insurance plan provides coverage to medical or healthcare services that are considered necessary services. Necessary services include all services necessary to treat or diagnose an individual’s medical condition based on the best medical practices.

EPO plans also provide coverage to services that prevent medical conditions and, ultimately, reduce future costs. Preventive care includes screening for cancer, taking vaccines, and stopping smoking or drinking, which prevents future medical complications.

How it Works

Individuals are encouraged to read through the policy their EPO provides. This process is useful as it keeps assurers in touch with changes in policies. Most importantly, this keeps an assurer informed about new and old (removed) accredited healthcare services providers, referred to as provider networks.

Provider network offers individual required types of healthcare services. These services include doctors, pharmacies, specialists, hospitals, imagery facilities, laboratories, therapists, and more.

A typical insurance company that provides EPO plan through a provider network would typically cover necessary and preventive services to assurers. Therefore, individuals that get any healthcare service from service providers that are not within the provider network of their insurer would have to bear the burden of the cost incurred. However, there is an exception to this rule in certain circumstances.

These exceptions are:

• In cases of real emergencies such as heart attack, severe injury due to accident, stroke, or any series emergency, individuals are allowed to access emergency care in health facilities that are not on the provider network. However, the EPO provider may ask the patient if stable to be transferred to a facility that is within their provider network.
• Individuals that transfer from one EPO insurer to another while undergoing a complex medical treatment may be allowed to complete the treatment. The insurer is going to consider each case based on its peculiarities.
• An individual that requires access to a specific treatment that is not offered by any facility within their insurer’s provider network can get coverage if there is a pre-arrangement between the insurer and the assurer. Also, the assurer must update their assurer at each step of the treatment to ensure payment.

Individuals that want to consult with a specialist can do so without a referral from a primary healthcare provider. But the assurer must ensure that the specialist belongs to the provider network of the insurer. Also, an assurer is not required to file a claim for payment.

However, assures are required to get authorization from the EPO provider before incurring expensive services. These services may include CT scans and MRIs, which are quite expensive, therefore, require pre-authorization.