“An HMO,” you sighed as you told your wife what insurance plan your new employers offers, “a good for nothing HMO”. She stares back in horror, as though you just told her that your new plans boasts leechings and anesthesia-free heart surgery. HMOs, it seems, have suffered a bad rap nearly since their inception in early 1970’s.
At first blush an HMO (Health Maintenance Organization) seemed like a fabulous idea. The entire concept was based upon the premise that a healthy member reduced overall heath-care costs due to the fact that less sick based services would be required. Thus, HMOs would cover all sorts of well visits in an effort to maintain a patient’s excellent health. Through the years, however, a general mindset developed that determined that HMOs were more in the business of denying coverage and the “health maintenance” piece of business fell by the wayside.
On the contrary, many patients that carry HMOs state that they are very satisfied with the coverage. The key appears to be aware of the restrictions of the plan and work with your primary care physician (PCP) to get the best possible care within the plan.
First, be sure when you sign up for an HMO that you are given a listing of participating providers. This will give you a general idea of who participates in your plan should you need specialty services such as physical therapy, podiatry or an oral surgeon. This listing should also advise you as to what hospital you will need to go to should you require inpatient or outpatient care.
Next, be sure to get a referral for every service that you receive outside of your PCP’s office. Please note that this includes diagnostic testing such as x-rays, MRIs and blood work. Read your referral carefully once you receive it and make certain that any services you receive fall within the guidelines of the referral. For example, if the referral is for an orthopedic surgery consultation be clear about whether x-rays are included in the referral.
Also, if you are having difficulty getting a referral from your PCP you may turn to the insurance plan directly and ask them to advocate on your behalf. There should be a toll-free customer service number listed right on your card.
Finally, be aware that unlike some other plans if you do not follow the proper referral guidelines with an HMO it will result in claims being denied. Not paid at a reduced benefit, but simply denied outright. This could leave you on the hook for hundreds or thousands of dollars so be sure to follow the referral guidelines listed here precisely.
Written by Sue De La Bruere
