In the HMO world, referrals and authorizations are intertwined. Last week, my husband saw his primary doctor in follow up for treatment for a DVT. In the previous visit, the primary care doctor mentioned that he might need to see a cardiovascular surgeon. In anticipation for this appointment, we looked on the HMO provider website to see what cardiovascular surgeons were in their network so we would be able to give the doctor the list of providers. There were several listed, so I printed off the names and put the paperwork with my things to take to the appointment.

We had an 8:15 am appointment to see the doctor. During the visit, the doctor did say he wanted my husband to see the cardiovascular surgeon. I handed him the list I had printed off. He reviewed the list and said he knew a few of the doctors and recommended one on the list. He went out and came back a few minutes later and handed us a form with the referral noted. He said good buy and said he would see my husband in a few weeks.

We left the office and went home. I called for the appointment for the cardiovascular surgeon office nd gave the insurance information to the staff person making the appointment. We lucked out and got an appointment for the following week!

On the appointed day, we went to the Clinic for our 8 am appointment. When we approached the registration desk, the receptionists started the intake and then asked for the authorization. My husband handed her the paperwork we had gotten from the doctor. The receptionist looked and it and said this is a referral, not an authorization. She then showed me what an authorization looked like and said this is what I need to register to him. My husband asked, how do we get the authorization? She said that you get it from your primary. As it was 7:50 am, I knew the doctor’s office was not going to be open. She said you can reschedule. My husband did not want to do that, so we asked what the cost was as we did not want to miss the appointment. She went to check and came back and told us it would be $200.00, and whatever the level of care was. She said the doctor would give us the level of care after he saw us. She also said that if there were any test ordered, we would have to pay more. My husband gave her his credit card and it was scanned into the system and the receptionist finished the check-in.

Next thing we knew, we were called into the back, and after getting his weight and vitals taken, my husband saw the doctor. The doctor examined him and reviewed his findings of the Doppler study he had had last week. He gave us the plan of care, which we agreed with, and we left.

The nurse told us we had to see the receptionist again on the way out. She added the level of care to the cost of the visit and told us owed another $85.00. I asked if she could wait to run the credit card until we tried to get the authorization. She said she already ran it, but if we got the authorization and had it faxed over before 5pm she would cancel the credit card charge. We thanked her and left.

After leaving the office, we went right over to the primary care doctor. We explained what happened, and the receptionists said, let me run the authorization right now. She came back a few minutes later with the authorization. We also had a minute to talk to the primary doctor and reviewed what the cardiovascular specialists recommended. He agreed with the plan and said he would see us in a few weeks and to call him if any issues.

My husband then went back to Cleveland Clinic and gave the receptionist the authorization. She said she would cancel the charge.

Lesson learned:

  1. If you have an HMO, know that to see a specialist, get specific tests, or have therapy, you need a referral and an authoriztion from your doctor.
  2. Know that a referral is different than an authorization. The primary care office knows how to get the authorization with the insurance company. It is usually done online and takes a few minutes so do not leave your doctor’s office until you know they are going to run an authorization. You might be able to wait for it, but if you don’t wait, get a name and the phone number who you can call to check on the authorization if it does not come through in a timely manner. You will need the authorization or you WILL NOT BE SEEN or as noted above, have to pay for the visit if you choose.
  3. Check to see if the primary care office will make your appointment to see the specialist or have the tests or services you need? Many times they will, but if not, you can do it.
  4. If you have a specific request as to who you want to see, make sure they are in your HMO network. Staying in your network is critical, as going out of the network is more expensive for you.
  5. If something like our experience occurs, don’t give up, see what the receptionist will do for you.
  6. Don’t be afraid to pay for a service if it is important to you. It can save you time, and it will allow you to ‘do what you need to do’ without delay. Most times, you will be reimbursed by your insurance company.
  7. Remember, you are THE customer, and you have a voice. As they say, ‘everything is negotiable so don’t be afraid to speak up and ask what can be done to remedy a situation.
  8. Know that there are rules to follow when it comes to insurance. HMOs are the strictest of all of the insurance policies.
  9. Take time to learn the various types of insurance. Here is a link to review the various types of policies. Check with your employer to see what options you have if you have an employer-sponsored plan. Some employers offer a PPO option in addition to the HMO option. A PPO gives you a little more freedom but it is also more expensive. If you are buying insurance on your own, study the various policies and choose the one that is right for you.
  10. Now that we had this experience, we are aware of the rules and what we need to do if our primary physician orders a service or suggests that we see a specialist.
  11. We now know there is a difference between a referral and an authorization!

I hope our experience provides some tips that will help you avoid this type of problem when you need a referral.

 

 

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