Posted in Health Systems

PCPs, PPOs, and Premiums: De-coding Health Insurance Terminology

Hello, blogosphere. The interview trail has kept me busy, so I apologize for the gap between these last posts. In light of changes with Marketplace insurance plans (i.e. Affordable Care Act, or “Obamacare,” plans), the purpose of today’s post will be to define all of the terminology commonly used regarding health insurance.

I will be using a fictional family, the Waytes, for illustration purposes. The Waytes family consists of husband Bill, wife Sandra, and young children Timmy and Susie.

Healthcare Provider (or Provider): your physician (medical doctor, MD or DO), nurse practitioner (NP), physician assistant (PA), podiatrist (DPM), or other similar professional who provides you with medical care.

Primary Care Provider (PCP) vs. Specialist: A PCP is a physician or other provider who is your “main” doctor or provider. He or she is a generalist and can evaluate and address most of your healthcare needs. When you have a more complex health issue, your PCP will refer you to a specialist, who is more extensively trained in a particular field.

  • Sandra and Bill regularly go to see their PCP, Dr. Garcia, an MD who is board-certified in family practice. She performs their annual wellness exams, coordinates immunizations, manages Bill’s hypertension, and prescribes antibiotics for Sandra when she has a UTI. Sometimes, however, Dr. Garcia consults specialist providers for the Waytes’ care, for example referring Sandra to dermatologist for a funny-looking mole.

Referral: the directing of a patient to a medical specialist by a PCP or other provider, usually requiring documentation of such (eg. a paper slip signed by the provider). Continue reading “PCPs, PPOs, and Premiums: De-coding Health Insurance Terminology”