Depending on the type of health insurance you have, you may not be able to go directly to a specialist when you think you need the services they provide.
If you have a Health Maintenance Organization (HMO) or Point of Service (POS) plan, you may need to see your Primary Care Physician (PCP) first. If they agree that you need to see a specialist, they will refer you to a specialist and record it in your medical file. Some health plans require referrals in writing, while others accept phone calls.
It pays to be proactive in order to make sure everything is fine with the specialist.Make sure your insurance company has received a letter of recommendation forward You make an appointment with a specialist. Only then will you know that your specialist doctor visit will be included in your health care plan.
This article explains how referrals work in HMOs and POSs, and how they are not needed in PPOs and EPOs. It also states how insurance payments for designated in-network services vary depending on whether the plan is in-network or out-of-network.
Referrals for HMO and POS plans
Health maintenance organizations require you to choose a primary care physician (PCP). The doctor then manages all of your future healthcare. This power includes making recommendations on treatment, medication and other issues.
The primary care physician also refers any other necessary services or specialist doctor visits. These referrals allow you to see another doctor within the health plan’s network. Your HMO is unlikely to cover the service if you don’t have a referral from your PCP.
Some modern HMOs relax these rules and allow members to access specialists within the plan’s network without a referral from a primary care physician. Therefore, you need to check the specific requirements of your program.
HMOs generally require members to obtain all care from providers in the plan’s network, whether or not referral is required. Out-of-network care is only covered in emergencies.
The point-of-service program also requires a referral from the PCP to see a specialist. But unlike an HMO, a POS usually covers some of the cost of out-of-network care as long as you have a referral from your PCP. (For HMOs, the referral must still be to a specialist participating in the plan’s network. This is the case unless there is no specialist available and the health plan makes an exception to ensure necessary care).
HMOs are becoming more common in the personal health insurance market as insurers struggle to control costs. Some state health insurance exchanges no longer offer any PPO options.
PPO, EPO bypass recommendation
Preferred Provider Organizations (PPOs) or Exclusive Provider Organizations (EPOs) do not require referrals. A PPO is a health plan that contracts with a broad network of “preferred” providers. You can also choose your care or service from the network. The EPO also has a network of providers, but it usually doesn’t cover any out-of-network care unless it’s an emergency.
Unlike a health maintenance organization, in a PPO or EPO, you don’t need to choose a primary care physician, and you don’t need a referral to see other providers in the network. Because of this flexibility, PPO plans tend to be more expensive than HMO plans, which are otherwise equally beneficial.
In fact, while PPOs are still the most common type of employer-sponsored plan, they are not as common in the individual market as they used to be, as insurance companies find them more expensive.
EPO health insurance – what it is and how it works
Depending on the services you need, prior authorization from your insurance plan may be required in addition to a referral from your PCP. Your PCP may automatically obtain prior authorization as part of the referral process. But as a general rule, before you receive treatment, double-check with your insurance company and specialist to ensure prior authorization has been obtained if required by the insurance company.
Insurance payments for designated in-network services vary depending on whether the plan is in-network or out-of-network.
within the network
Whether you have an HMO, EPO, POS or PPO, for in-network services, if your plan uses it, you will be responsible for co-payments and deductibles and coinsurance (these different types of costs – sharing applies to different services; You may only get copays for services, or you may be responsible for deductibles and coinsurance).
Employer-sponsored HMO, POS, and EPO plans tend to have lower deductibles and copays than PPO plans. But this is usually not the case with plans purchased in individual markets. Those self-purchased plans (through an exchange or directly from an insurance company) typically have similar cost-sharing regardless of the type of plan administration.
Employer-sponsored PPOs tend to have higher cost-sharing than other types of employer-sponsored insurance. However, if you’re shopping for your own health plan, you may find that only HMOs and EPOs are available in your area. And their cost-sharing can be very high (if you qualify for the cost-sharing waiver and you’re buying your own plan, pay special attention to the Silver plan, as the cost-sharing waiver only applies to the Silver plan).
7 health insurance concepts you need to know
out of network
With an HMO or EPO, you generally don’t get any coverage for out-of-network services unless you’re in the throes of an emergency. With a PPO or POS, out-of-network care is usually covered, but the provider is free to bill you for what your insurance company doesn’t cover because the provider has not yet signed a contract with your insurance company. (With POS, you need Any coverage for out-of-network treatment requires a referral from your PCP.)
When a person’s health plan is renewed in 2022, they can’t get a balance bill for urgent care or from an out-of-network provider who treats them at an in-network hospital. This is due to the federal No Surprise Act, which has played a major role in protecting consumers from out-of-network billing when they essentially have no choice but to use an in-network provider.
For other situations where you choose to leave the network for care, you will usually be required to pay the provider first and then be reimbursed by the PPO. Most PPO plans have high annual deductibles and out-of-pocket maximums for out-of-network care. Some PPO plans have no limit on the out-of-pocket costs you will incur if you leave the network.
Balance billing basic
Balance billing occurs when a provider charges you the difference between the provider’s fee and the allowed amount. For example, if a provider charges you $200 and the allowed amount is $100, the provider may charge you the balance or $100. But starting in 2022, “surprise” balance billing is no longer allowed. This means that patients will no longer receive balance bills from out-of-network providers or out-of-network providers who treat them at an in-network hospital in an emergency.
Health Maintenance Organizations (HMOs) require people to choose a Primary Care Physician (PCP) who has no small role: this person manages all the details of a patient’s healthcare. Primary care physicians also provide referrals for any other necessary services or specialist visits within the network. These referrals allow you to see another doctor or specialist within the health plan’s network. If you don’t have a referral from your PCP, your HMO may not cover the service.
Some modern HMOs relax these rules and allow members to access specialists within the plan’s network without a referral from a primary care physician. HMOs generally require members to obtain all care from providers within the plan’s network, regardless of whether a referral is required, and out-of-network care is only covered in emergencies.
Also, Point-of-Service (POS) plans require a referral from a PCP to see a specialist. But unlike an HMO, a POS usually covers some of the cost of out-of-network care as long as you have a referral from your PCP.
Preferred Provider Organizations (PPOs) or Exclusive Provider Organizations (EPOs) do not require referrals. However, it is still a good idea to have a primary care doctor and let them know about your medical treatment. They can help you coordinate your care and make sure you get the treatment you need.
You have every right to appeal a health insurance company’s decision, such as when it refused to cover medical services and you don’t know why. If you need help navigating your paperwork, you can find it through the state Consumer Assistance Program (CAP). Not every state has a CAP office, so check your state office first. The program is designed to help consumers with insurance issues. CAP provides this assistance by phone, direct mail, email, or at a walk-in location.