What Is A PPO For Worker’s Compensation?

Lawyer in McHenry County, Workers Compensation

A Preferred Provider Organization (PPO) is a health insurance plan created for individuals and families which involves a network of contracted medical professionals and health insurance companies. Healthcare professionals offer services to the policyholders of the insurer’s plan at a reduced rate.

PPO plans are usually more comprehensive in their coverage and offer a broader range of services than HMOs. Physicians, healthcare professionals, and facilities that provide their services under this insurer’s plan are known as “in-network” providers. They are listed under a “preferred provider list” for employees to choose from.

In contrast, doctors and other healthcare professionals not listed under the “preferred provider list” are known as “out-of-network” providers. Members of a PPO plan can obtain care from a specialist doctor without a referral from their primary physician. It eliminates delays and unnecessary hurdles when they need medical care.

How Does A PPO Plan Work? 

When employees covered under a PPO plan seek care for work-related injuries from an in-network provider, the insurance company must pay the provider the agreed rate. The employee will have to pay any co-pay or deductible on the fee.

This is different when employees opt to receive care from out-of-network providers, as they are required to pay more than what the health plan is willing to pay in addition to their share of the costs.

For instance, you sprain your shoulder while working and need an X-ray which will cost $450. Using an out-of-network provider on your plan will cost you 35% co-insurance, which comes down to a fee of $157 while using an in-network provider will only cost you 20%, which is $90.

Employers must provide injured workers with the Notice of Preferred Provider Program for Worker’s Compensation Medical Care issued by the Illinois Worker’s Compensation Commission immediately after reporting the injury.

What Injuries Are Covered When You Use a PPO For Worker’s Compensation? 

Before the insurance company considers covering your medical care, you must determine that your care is necessary and that you sustained your injury while working at your workplace. Worker’s Compensation insurance covers all injuries or illnesses employees develop while working.

The employee does not necessarily have to be hurt on the company’s property. It is important to note that worker’s compensation will not cover all injuries at work. For instance, insurance covers your injuries if you get involved in a car accident while working. Still, if you slip and sprain your wrist in the break room while hanging out with your coworkers after work, you will most likely need to use your insurance to pay your hospital bill. When deciding if a PPO plan is right for you, you must consider the costs, as the premiums are higher than other medical insurance plans.

Whenever you have any questions about whether your injuries are “work-related,” ensure you report the accident to your employer and seek legal advice from a work injury lawyer. Reach out to us at Franks, Kelly, Matuszewich, and Andrle Attorneys at Law, and we will provide solid legal representation and counsel to you.