How do HMO referrals work?

[HappySaver]

I've just switched to an HMO for the first time. I've always had a PPO before. I have an appointment this week with a specialist that was already scheduled well in advance of switching health plans. So I was not asked for a referral when I first made the appointment. Because the appointment was already scheduled when I switched plans, will the new insurance company still require a referral from my primary care provider?

Basically, I'm not sure if referrals are required only for scheduling appointments, or if HMO insurance companies require them before they will cover the visit?

I already know that the specialist is inside the HMO network, and also that my PCP is out of town this week so I couldn't get a referral from her this week if I tried. I've been a regular patient of both physicians for some time now and they work with each other on my care.

[disneysteve]

I've just switched to an HMO for the first time. I've always had a PPO before. I have an appointment this week with a specialist that was already scheduled well in advance of switching health plans. So I was not asked for a referral when I first made the appointment. Because the appointment was already scheduled when I switched plans, will the new insurance company still require a referral from my primary care provider?

Basically, I'm not sure if referrals are required only for scheduling appointments, or if HMO insurance companies require them before they will cover the visit?

I already know that the specialist is inside the HMO network, and also that my PCP is out of town this week so I couldn't get a referral from her this week if I tried. I've been a regular patient of both physicians for some time now and they work with each other on my care.

Yes, you will need a referral issued by your primary doctor. If she is out of town, her staff can still issue the referral as it isn't the doctor who actually does that anyway.

[HappySaver]

Thank you. I called my doctor's office and the person who issues referral is also out this week, but they said she would back-date the referral so I left my information for her. Just as long as there's no danger I would have to pay for the visit out of pocket.

[disneysteve]

the person who issues referral is also out this week

I can't imagine running my practice this way. I have 4 staff members and all 4 know how to do referrals. Having only one could be a disaster. What if that person gets sick? What if they quit? What if they go on vacation (as in this case)? We couldn't function if we couldn't provide referrals for a week. Not all insurance companies allow referrals to be back dated.

[kv968]

I'd check with the HMO first to see if you do in fact need a referral. I'm in an HMO (Aetna Choice POS II) and I don't need a referral to see a specialist nor do I have to pick a PCP.

With most HMO's you do have to do the above but there are a lot of different plans even under the same company (i.e. Aetna, UnitedHealthcare, etc...) so I'd check to make sure what your exact benefits are and if you do need a referral first if you haven't already.

[disneysteve]

I'm in an HMO (Aetna Choice POS II)

HMO and POS are not the same thing. They are different types of plans so they have different rules and regulations. So kv, it isn't accurate for you to say you are in an HMO because you are not. You're in a POS. There are also PPOs and EPOs and each type of plan has slightly different rules regarding things like referrals, choosing a PCP, getting prior authorizations, etc.

[kv968]

HMO and POS are not the same thing. They are different types of plans so they have different rules and regulations. So kv, it isn't accurate for you to say you are in an HMO because you are not. You're in a POS. There are also PPOs and EPOs and each type of plan has slightly different rules regarding things like referrals, choosing a PCP, getting prior authorizations, etc.

Thanks for correcting me Steve. I just knew that I was in an HMO with Aetna and it switched to a POS but still with Aetna so I just assumed it was still an HMO.

Gotta keep up on my acronyms And they wonder why the healthcare system is so screwed up?!?

[disneysteve]

Thanks for correcting me Steve. I just knew that I was in an HMO with Aetna and it switched to a POS but still with Aetna so I just assumed it was still an HMO.

Gotta keep up on my acronyms And they wonder why the healthcare system is so screwed up?!?

Agreed. Imagine what we deal with every day when we ask a patient what insurance he has and he just says, "Aetna." That tells us essentially nothing as Aetna offers dozens of different plans.

[kv968]

Agreed. Imagine what we deal with every day when we ask a patient what insurance he has and he just says, "Aetna." That tells us essentially nothing as Aetna offers dozens of different plans.

I feel for ya. Like I've said, when they're offering degrees in medical billing and coding you know it has gotten WAY too complicated.

[Williamschmit]

I think you may have have to do the above but there are a lot of different programs even under the same organization.

[Williamschmit]

I think you may have have to do the above but there are a lot of different programs even under the same organization.

HMO referrals work wouldn't be too much difficult. I think one must start up and precisely it could have become more feasible if he is an expert in such field.