I’ve been seeing the same specialist for several years, and now you have referred me to someone I don’t know. Why can’t I continue to see the same doctor?
I suggested a specialist in my referral circle so that I can better coordinate your care and advocate for you. However, I would like to learn more about the relationship you have with your specialist so that we can come to an agreement on what will work best for you.
I disagree with Provider’s decision. What can I do?
I’m sorry you feel this way. If you are concerned about a health care decision, it is important to discuss it with me. I’m committed to making sure you get the best care and that there is timely and effective communication among all the doctors you see.
OPTIONAL COMMENT: If you would like to see a doctor outside of this team, you always have the option to choose a new primary care provider.
If you can’t give a referral to [XYZ] physician office, do I have second opinion?
You do have second opinion benefits under your HMO plan—and this would be coordinated through my office [PCP’s practice] using the qualified providers within my referral circle. Let’s work together to discuss your needs and expectations, and then determine which specialist you should see.
I don’t understand – why can you only refer within this affiliated group and not to the physician group I want to go to? I’m frustrated.
I’m sorry you feel that way. Working with specialists in my network will allow me to better coordinate your care and advocate for you. Let’s talk about your frustrations and see if we can find a solution together.
I’m in an HMO plan. What do I need to know about getting covered services?
As a member of a “health maintenance organization,” you need to understand the basics of how to use your plan so that you know how your health care services are covered.
This includes understanding that:
You must select a primary care provider (or PCP) to coordinate your care.
1. If you see a specialist, you must have a referral from your PCP. (If you see a specialist without a referral from your PCP, you may be responsible for the entire bill—not just a copayment or deductible.)
2. If you see a specialist, you may be responsible for the paying out-of-pocket for services that have not been approved, arranged, or provided by your PCP.
Please remember that you are responsible to confirm with your Health Plan if the services provided to you will be covered and to ensure that necessary referrals or authorizations are obtained before your visit. Our practice works with your Health Plan to obtain the referral/authorizations on your behalf, but the ultimate responsibility is yours. You are also responsible for paying for covered services that are subject to your deductible, if you have one, until your deductible is satisfied.
A friend of mine just had surgery at [XYZ] Hospital and highly recommended I go there as well. Can I go there for my treatment?
As your PCP, I want to coordinate your care with the specialists my practice collaborates with. I know your history and health care needs and can help you decide whether a specialist visit is needed. I refer to specialists I know and trust and with whom I have a working relationship. This way, I can coordinate with your specialist and, together, we can provide you with the greatest degree of collaboration to help you get high-quality, timely, and effective care.
What if I don’t agree with you?
Our relationship is a partnership that is built on trust. I am committed to working with you so you get the care you need to keep you healthy. If you still disagree with my recommendations, you always have the right to change PCPs. But I hope you understand that my first priority is your health, so every decision is made to coordinate your care.
My child is being treated for hearing issues at [XYZ] Hospital. I’d like to have his vision evaluated there as well. Can I continue taking my child to [XYZ] Hospital for this new issue?
I refer to specialists and hospitals within my referral circle because this allows for better coordination of care. Let’s discuss your concern so we can work together to meet your child’s needs.
I just transferred from a PPO plan to an HMO, and my PCP is with a new group. When I called for a referral for a specialist I have seen before, I was denied. Why can’t I continue to see the specialist of my choice?
There are major differences between a PPO and an HMO. First, a PPO does not require a referral—you can see whatever provider you want. An HMO, on the other hand, requires that a PCP coordinate all your health care needs. As your PCP, I work with you to coordinate any services or treatments you receive. In this role, I know and understand your health history and your health care needs—including whether you need to see a specialist. When you do need to see a specialist, I will refer you to a member of my own high-quality provider team. We will work collaboratively to see that you get the care you need at the right place and at the right time.