Here's a first-person example of what can go wrong with the PPO model and why more than ever you must "manage" your own care and not trust your doctor or insurance company to do what is in your best interest.  If you are an employer, you should print out this article, and pass it on to your employees so that they and you as the employer don't get ripped off.

During the holiday season, I contracted the dreaded fever/runnynose/sore throat condition.  Nothing serious, but after a week the sore throat and fever had persisted and I decided to do something about it on a Sunday rather than face another work week of misery right before the Christmas holiday.   Even if I had strep throat, a generic antibiotic prescription was a quick $4.00 solution to fix what ailed me.  Unfortunately, I first had to find, visit and pay a doctor who worked on Sundays to write me the script that the pharmacy would accept along with my $4.00 before I could get the generic antibiotics I needed ro shake the fever and sore throat.

I first drove to two 24 hour urgent care clinics located a few miles from my home.  At both locations,  I walked up to the front desk, explained what ailed me, and asked if the clinic was in my insurance carrier's PPO network.  And at both locations, the receptionists had been well-trained to avoid my question. They stated that yes, their clinic would be happy to submit my paperwork to my insurance company.  But only after a third time, when I asked to give me either a yes or no answer if they were in my PPO network did I get the truth, that they were not a network provider.

Because the clinics were not in my PPO network, they did not have a contract with my insurance company and could charge whatever they wanted.  And since my health insurance is a high deductible health plan, I pay out of pocket for any medical expenses at the negotiated network discount until I meet my (high) deductible.  So in theory, I should pay less for my care if I went to a doctor that was in my insurance company's network.

I walked out of both clinics, disgusted with answers from medical providers that bordered on dishonesty just to take my money. I decided not to waste any more time with walk-in visits and went home to search my insurance carrier's online PPO directory for walk-in clinics that were in the network.  Fortunately, I found one clinic that was still open on the Sunday afternnon.  I called for an appointment and drove to the clinic, walked to the front desk, presented my insurance card, filled out the paperwork at the front desk and then sat down to wait to see the doctor.

When my time came to meet with the doctor he briefly examined me to satisfy for himself that I indeed had a fever and runny nose, and he then had an assistant take a throat culture to test for strep throat.

Another trip back to the waiting room and fifteen minutes later it was confirmed that I did not have strep throat, and another fifteen minutes later the assistant then handed me the script for the generic antibiotic.  The clinic would bill my insurance carrier and I finally could drive to the closest discount store and pick up my $4.00 generic prescription, paying for it out of mr health savings account discount card.  Two days later and the fever was gone, and a week later the sore throat and runny nose were gone as well.

But when the bill arrived in the mail I found that the doctor had charged a higher "discounted" rate than either of the out of network clinics would have charged.  I then called the doctor's office the and asked the receptionist what it would cost for a visit if I didn't have insurance and found out that the rate given was substantially less than the rate he charged me.  I asked if I could speak to the doctor and that I had a problem his bill.

After a short wait, I spoke to the doctor who justified his higher price for patients who had insurance because he had to employee three people on his staff to submit paperwork and the insurance companies were slow-payers.  I explained that that was violating his contract with my insurance carrier's PPO by charging more, and refused to pay one cent until he agreed to charge his cash price.  He agreed to do this if I paid the bill promptly, which I did.

Was this doctor right to charge me more because it cost him more to deal with insured patients than cash paying customers?  Probably not.  A PPO network discount from having health insurance coverage should always cost less, not more.  Does it happen?  All the time.

The moral of the story?  Patient beware: Never answer the question "do you have insurance?" without first asking the question, "Do you have a cash discount?" Once you know whether the doctor or clinic is playing games with billing rates, then and only then should you ask whether the doctor or clinic is in your insurance carrier's PPO network.

The other moral of the story: Obtaining generic meds  to treat minor illnesses such as a routine fever shouldn't be this hard or complicated.  Many pharmacists administer blood tests and vaccines; allowing them to administer generic meds without a prescription from a doctor for minor routine illnesses if customers test positive for something like a fever or sore throat seems like an easy way to reduce healthcare and insurance expenses.