When Selecting Your Providers -

Narrowing Your Options

You are ready to start selecting your providers. You have an idea of what types of services/benefits you want included in your health insurance policy. You have an idea of how much you are able/willing to pay for these services. Now, you need to consider how you want to access the services. Here are some things you should think about when considering HMO, PPO or POS plans:

The HMO plan is great if you:selecting your providers

  • Do not travel for work or pleasure. If you travel for work and/or pleasure and find that you are frequently accessing medical care outside of your HMO network, the group could ask your insurance carrier to have you removed as a member and, your insurance carrier may not consider you a candidate for an HMO plan if you are frequently away from your primary home address.
  • You feel comfortable with all of the physicians within the group. If you do not feel comfortable with all the specialists in the network or, with the primary care physician (PCP) who may be caring for you when your doctor is on vacation, you may wish to reconsider the group, or whether or not you want to be a member of a HMO.
  • Do not have any complex healthcare issues which may require immediate hospitalization or referrals to specialists (remember, you must have the permission of your PCP for any hospital admissions or referrals to specialists).
  • You can afford to wait for physician appointment. Waiting for doctor appointmentWhile selecting your providers, remember that most HMO’s do have a quota. In order to keep costs down and revenue up, your PCP will be required to see a set number of patients per day. If they do not meet their quota, they may be penalized or be removed from the group. They may also be penalized if they issue too many referrals to specialists.

    While it is illegal for groups to provide monetary incentive to physicians to see more patients or limit referrals to specialists, it does not mean that the quotas don’t exist. While a physician may not receive payment from a group, the potential of being removed from the group if quotas are not met can be enough of an incentive!

If you do elect to go with a HMO, as with anything, you need to do your homework!!!selecting your providers

  • Interview current members of the HMO you are interested in and see if they have any experiences that may be a red flag to you (maybe they have had to wait for 3-6 months for an appointments or their PCP is slow to provide referrals. Maybe they were only able to get appointments quickly if they were willing to see someone other than their PCP).
  • Interview the hospital and physicians that are part of the network, as part of the work of selecting your providers. Walk through the hospital and observe the cleanliness and attitude of the staff. Assess the working relationship between the nursing staff and physicians. Review the list of physicians, especially surgeons. Again, you may wish to interview people you know who have been under their care. Be sure the hospital has been approved by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and licensed by your state.
  • Be sure you clearly understand all the rules and restrictions before signing up with any HMO!!!!! HMO's do have quite a few restrictions. You could be penalized for non-compliance.
  • As you are choosing your doctor, check to see if your current physician is a member of an IPA. If he/she is, you may not have to change physicians! You may consider requesting the opinion of your current physician. It may be interesting to see how many HMO physicians would select an HMO plan for themselves or their families!
  • Check with your insurance provider or with your State of residence to see if there are any complaints filed against the HMO or IPA you are interested in joining. Some insurance carriers will provide a "grade" or rating system of participating IPA’s and HMO’s which you can view online.
  • You may wish to assess how many denials for care are overturned by the group or your provider.
  • Does the HMO/IPA provide coverage for experimental and investigational services (in most cases, this must be reviewed to determine if the services requested meet with the FDA guidelines and community standards).
  • Does your HMO offer Urgent Care facilities in your area?
  • Review the prescription benefits. Is the group willing to consider the use of the newer medications or are they restricted to “formulary” drugs only.
  • You may want to visit the office of the PCP you are considering. Sit in the office and see how long the wait time is. You may wish to interview those waiting in the office. Was this physician their first choice or were they assigned to this physician by the group? Have they had problems obtaining specialty referrals? Have they ever had any requests denied?

Remember, right now when you are healthy is when you want to find the answers to these questions as you are selecting your providers. You don’t want to find out that your HMO was ranked poorly when you are sick and in need of urgent care!

I prefer to interview my healthcare team. In much the same way you would be interviewed for any job, it is my humble opinion that you should be able to interview any candidates seeking the position of "healthcare provider."

If I am going have to undergo surgery, I want to know the person playing with my insides is someone I have checked on, trust and have hand-picked. I want to know the hospital I am going to is a place that is certified and has staff that I can rely on.

The front office staff of a physician's office is also important to me. Even if my physician won the Noble Peace Prize for his/her area of expertise, it does no good to me if his/her office staff is not able to forward a simple message to him/her!!!! I know you have experienced less than competent office staff and can appreciate what I am saying!

If I am selecting an individual policy, I will also interview providers to see if there are any issues with the insurance carrier. Physicians' offices are more than happy to tell you which insurance provider pays their bills quickly and approve their requests, and which give them grief!

Because I have health issues of my own, it is important for me to be able to go to a specialist of my own choosing when I want to, and not have to wait for a group to provide authorization.

If you are like me, then the PPO plan is your best bet.

Point of Service (POS) plans are great options if you want the best of the HMO and the PPO. You are able to take advantage of the HMO’s low co-pays by accessing the services from the group’s PCP. You also can enjoy the flexibility of going outside the network and selecting your own team of specialists for the cost of a slightly higher co-payment. This feature can come in handy if you would like to seek a second opinion from outside the group’s network of physicians.

The down side to the POS plan is: selecting your providers

  • The monthly premium cost is higher than an HMO (but, typically not as high as a PPO plan)
  • There may be a set dollar amount attached to your out-of-network/self-referrals. If you are planning on primarily using the PPO feature, then you will want to purchase a PPO plan.
  • You may have to submit your own claim/paper work.