HMOs And Referrals
How can I tell if a treatment is covered by my HMO plan?
HMOs are required to pay for medically necessary care, generally, and they are not required to pay for things they specifically exclude. So the most important part of your health insurance contract is to turn to exclusions and limitations pages, and you'll look in your health insurance contract, and there will a bold setting, exclusions and limitations. Before you do anything else with your health insurance contract, go to the exclusions and limitations, see what they specifically exclude and you can look for generality's. And with something that seems too general, ask them, what are the most frequently denied procedures under your exclusion for experimental, your exclusion for investigative? Ask the broker, ask the sales people these questions. They'll think you are very wise, and at the same time be very guarded in their answers, but it will help get you further down the line, and at least show them that you are a very informed consumer.
Why does my HMO require my primary doctor's referral for a specialist?
That's part of your HMO's managing your care. Again, the way they limit costs is to make sure that you don't choose to just go to someone who, for sake of argument, may be unnecessary. You may not need a dermatologist or you may not need a cardiologist. Your primary care doctor, who is cheaper, may be the best first stop, so they always want you to go through your primary care physician before you go to a more costly specialist. That's their reason to require your primary doctor's referral for a specialist. They could argue that they want the best medical care for you at the lowest level possible, and I argue they want the cheapest care for you at the lowest possible level.
What if my primary care physician won't refer me to a specialist?
Within an HMO, if your primary care person does not refer you to a specialist, you can ask for another primary care doctor, or you can go directly to a specialist. You have to be careful that in most of these systems with gate keepers or the person you must go through first, if you do go to someone without their consent, you're obligated to pay.
Will my HMO cover a 'second opinion'?
Some HMO's, depending on their state laws, won't cover a second opinion. If it's a major operation, or anything important, usually a second opinion can be as cheap as $100 to $150. I always tell people that they should go and get the second opinion, and worry about paying for it later; and try to get it from the insurance company, because your health and major decisions regarding surgery are much more important than the reimbursement.
What if my HMO refuses to allow me to see a specialist?
There's two means. You can fight your HMO if they refuse to allow you to go to a specialist, through letters. Using your doctor is usually your best arsenal. The doctor can write a letter and can advocate, or you can assist your doctor in writing a letter. The doctors are inundated with paperwork and they don't get paid for writing letters, unlike lawyers. If you can assist them any way, prepare a letter and see if they will sign it and put it on their own letterhead. That is really helpful to move the process along. In getting anything approved that hasn't been approved, or the chance to see a specialist, your doctor is your first line of the battle. Secondly, you write to the insurance company, you write to their CEO, and you write to the medical director. Thirdly, you should go pay for it on your own. Go directly to the person you feel you need to and then seek reimbursement later.
What kind of documentation should I keep when dealing with my HMO?
You want to get a copy of the contract. A lot of times HMO's don't even send you the contract. You want to see what's covered and what's not, because that helps you in discussing your 1-800 person. On page 32 of your contract, it says you pay for these, can you please help me get this covered. So it's really important to have your HMO contract, and the most explicit version, because they're happy to send you a summary of benefits, it kind of just gives you a little idea, but you want the actual contract between your health insurance company and you. Secondly, it's important to keep all authorization requests from your doctor, as well as authorizations; because that is your pre-approval. That is your ticket to get where you need to, and if they somehow down the line refuse to pay, you can always show them that authorization, which is in effect, a contract agreeing to pay for your treatment.
What should I watch out for if my HMO refuses to allow me to see a specialist?
The most important thing is if your Health Maintenance Organisation (HMO) refuses you to see a specialist. Then you have a disease that is going to be untreated, and that may cost you your life. So the first important thing is to get to that person however you can. It may take numerous calls to get to that doctor if you believe it's necessary. But, again, go back to your primary care doctor, and argue and fight with that person to be your advocate on behalf of you against the HMO. Secondly, go straight to that specialist yourself. Usually a special visit is not terribly expensive and you can fight them to get it covered later.
Is there a downside to going to a specialist without a referral from my HMO?
The only downside to going directly against the HMO's consent and going to a specialist is that you might have a tougher time getting reimbursed for it. It's going to boil down to medical necessity, but if there's a concern that seeing a specialist will give you greater peace of mind and allow you to sleep at night, it's worth the battle to go get the treatment, to make sure you're okay and to sleep better at night.
