Health Insurance Articles
Seeking A Specialist Through A Managed Care Plan
2011-09-15
A managed care plan can be a much less costly health care option than indemnity health insurance, as managed care plans use a specialized network of doctors to keep health care costs and insurance premiums as low as possible. This means lower rates and lower out-of-pocket costs for patients, but because managed care policyholders have less freedom of choice, it can also mean that obtaining certain types of medical care can be difficult. Plan members need to follow a specific process in order to see a health care specialist, for example, and attempting to see a specialist without following the proper procedure can mean a denied claim.
There are two types of managed care plans, PPOs (also known as preferred provider organizations) and HMOs (also known as health maintenance organizations). The process for seeing a health care specialist depends on the type of managed care plan that a patient is using. Under an HMO, a patient will have to get an authorization from his or her primary care physician. The primary care physician is a doctor in the HMO's network, usually a pediatrician or a general practitioner. After the primary care physician recommends a specialist, the patient will have to contact the HMO, who will assign a specialist from the network. If a specialist isn't available, the patient may be covered for out-of-network care at no additional cost, although this will depend on the terms of the patient's health plan. This process keeps cost down for the health maintenance organization, as it allows the HMO to prevent patients from visiting specialists when a general practitioner is capable of handling the patients' health care needs.
Under a PPO, a patient may have more freedom to see a specialist and receive health care and may be able to choose his or her own health care specialist. However, many PPOs still require a visit to a primary care physician or an evaluation by a general practitioner before a visit to a specialist can be approved. Again, this is done to keep costs down and to ensure that the health insurance company only pays for valid health care claims.
Before making an appointment with any type of specialist under a managed care plan, patients should contact their insurance companies to discuss the proper procedure for receiving authorization. Many managed care plans will issue pre-authorization documents that will indicate the types of testing and specialized health care services that will be covered under the patient's health care plan. These documents are crucial to ensuring a full payment of medical claims when any patient requires the services of a health care specialist.
