You are here: Home Insurance Health Insurance: ... HMOs: How To ...
Information about all aspects of finances affected by a serious health condition. Includes income sources such as work, investments, and private and government disability programs, and expenses such as medical bills, and how to deal with financial problems.
Information about all aspects of health care from choosing a doctor and treatment, staying safe in a hospital, to end of life care. Includes how to obtain, choose and maximize health insurance policies.
Answers to your practical questions such as how to travel safely despite your health condition, how to avoid getting infected by a pet, and what to say or not say to an insurance company.

HMOs: How To Maximize Use Of A Primary Care Physician


One of the most important aspects of maximizing use of an HMO is to choose a Primary Care Physician (PCP)  with care.  In addition to acting as your general doctor, the PCP also holds the key to your care in the rest of the system.

  • When you join an HMO, you are given a list of the primary care physicians who are part of the plan, together with some limited information about their background. It's your job to find a physician that works for you. It is preferable to have a PCP who is a skilled doctor with whom you are comfortable enough to share your most personal and perhaps embarrassing issues. Unless the person is also a specialist in your medical condition, it is helpful if the PCP is familiar with your condition and its treatment.
  • To find and choose your PCPconsider the following:
    • If you are happy with your current doctor 
      • Find out if he or she is a member of the HMO.  If not, let the doctor know that you're getting involved with the HMO, and ask if the doctor would be willing to join it so you can continue your relationship.  If the doctor won't agree to join the HMO, ask why. The answer may give you important information about the HMO. Also ask the doctor to look through the HMO directory and see if there are any doctors he or she would recommend.
      • Note: Some people who are forced to leave their doctor because of their HMO pay from their own pocket to visit their "old" doctor every quarter or so to review what treatments the HMO is providing.  Either you can convey suggestions from the "old" doctor to the new one, or perhaps the new doctor will be agreeable to speaking directly with the "old" doctor.
    • If you want a specialist to be your PCP
      • It is generally better to have both a primary care physician and a specialist for your condition. The specialist focuses on his or her specialty. The PCP takes care of your overall health. The PCP can also be a good person with whom to discuss questions bout treatments a specialist recommends.
      • However, if access to a specialist is a hassle, find out if a specialist in your condition can be your primary care physician. If this is not the norm in your HMO, ask to speak with a supervisor, let him or her know you understand the rule, but that you would appreciate an exception in your case.
      • If you have had your condition for a while, perhaps you can refer to an incident that happened to you that indicates it would be less expensive to treat you if your PCP were a specialist rather than a general practitioner.
      • If you don't have such an example, remind the supervisor that studies have shown that people do much better if their doctor is a specialist in their condition.
    • Find out if the PCP can permanently refer you to the specialist.  With a permanent referral, you do not have to go through the primary doctor each time you want to see t he specialist. With a permant referral, the importance of the PCP is reduced to being willing to make the permanent referral. If you can't obtain a permanent referral, try to obtain a referral that permits you to go to the specialist a number of times, such as 5 or 10, without having to ask for permission again.
    • Keep in mind that you always have the right to change PCPs. 
      •  If you find that you're not in agreement with your PCP's recommendations about treatment, or the doctor doesn't accept your input, or you lose confidence in the doctor as an advocate for you with the HMO, don't wait to make a change out of embarrassment or concern for your doctor's feelings.
      • Check the rules about changing PCPs. HMOs generally make it fairly simple to make a change. Changes usually become effective the first of the month following the request. There are a few HMOs, which only permit changing once a year, although even they have exceptions, such as permitting an earlier change if you move to an area which is no longer near your PCP. To learn more, see: Changing Doctors).
    • To help you find the person you want as Primary Care Physician, see: How To Choose A Primary Care Doctor

Get to know your doctor (and be sure the doctor knows about you). Once you have chosen your Primary Care Physician, don't wait until you're sick to see if you picked the right one.

  • Make an appointment for a physical exam if covered by the plan or for another reason if physical exams aren't covered or if it will be too long before you can get an appointment for a physical exam. Before you go to the meeting, read Preparing For An Office Visit.
  • Introduce yourself.
  • Present your new doctor with a copy of your medical records [see Medical Records] if the doctor doesn't already have them.
  • Ask the questions listed in Questions To Ask A Primary Care Doctor.
  • Show the doctor your List of Medications. Are they all included in the HMO's formulary?) If not, what substitutes can the doctor recommend? How do they differ from the drugs you are taking?
  • If your PCP is not a specialist in your condition and your condition requires the frequent use of specialists, ask about that process.
    • How much time does it take to get a referral?
    • How difficult are referrals to get?
    • How many visits to a specialist can you get with each referral? Can the approval be for an unlimited number of visits, or at least multiple visits, such as 5 visits
  • Find out about the doctor's potential conflicts of interest. With managed care, the doctor may have a financial interest in limiting your care. Explain that you are not trying to pry into the doctor's finances. You are only trying to understand all the factors that may impact on your care. Ask:
  • Whether the doctor is working under a capitation arrangement.
  • Whether there is a "gag" clause which prevents the doctor from telling you about certain drugs or treatments.
  • Whether the doctor is limited in the drugs he or she can prescribe.

After your interview, review the questions in Considerations After An Interview With A Doctor. Then listen to your "gut." This is the beginning of a very important relationship.

You always have the right to change PCPs.

Learn how to get what you need from him or her.  

You can get excellent care from an HMO even though you may have more difficulty getting care from an HMO than from other types of insurance. However, getting what you need will take vigilance and assertiveness on your part. It will also take the support and cooperation of your primary care physician.

To get the best possible care from your HMO, it is preferable to:

  • Learn what to do to maximize your time with your doctor.
    • For instance, learn about your condition. It is particularly important to learn about the various tests and treatments that are generally used with respect to your condition in case your HMO limits the tests and treatments. The objective is for you to have a yardstick against to measure what you receive from the HMO -- as well as a standard to argue for if you're not getting it.
    • To learn more, see How To Work Effectively With Your Doctors
  • Ask your doctor about the HMO bureaucracy
    • What tests and treatments require preauthorization?
    • Is approval easy or difficult to obtain?
    • What is the doctor's opinion of the preauthorization procedure? (The doctor's experience with the system often reveals how much trouble you'll have with it. Plus the question helps you bond with the doctor.)
    • Let the doctor know that you consider him or her an ally, not an adversary, in the HMO procedure issue.
  • Stay on top of referrals to specialists
    • If your doctor requests a referral to a specialist, ask how long it will take to get an approval. You should know from your knowledge of your condition and discussions with your doctor how important prompt treatment is.
    • If you haven't heard, call the doctor at the end of the time period and ask the status. Continue calling daily "just to follow-up" until you have the results or a new timeline. Be willing to talk to others besides the doctor as long as they know of the situation and keep the doctor apprised of your calls.

Please share how this information is useful to you. 0 Comments


Post a Comment Have something to add to this topic? Contact Us.

Characters remaining:

  • Allowed markup: <a> <i> <b> <em> <u> <s> <strong> <code> <pre> <p>
    All other tags will be stripped.