Navigating the HMO Maze: Unveiling the Reality Behind Medical Referrals and Coordinated Care
In HMO (Health Maintenance Organization) plans, medical referrals are crucial in managing healthcare services. A medical referral is a recommendation made by a primary care physician (PCP) to a specialist or another healthcare provider.
After a referral is made in an HMO plan, several steps typically follow:
The primary care physician (PCP) provides relevant medical information about the patient to the specialist. This information helps the specialist make informed decisions about the patient's healthcare needs.
The specialist evaluates the patient based on the referral information provided by the PCP. They may conduct further tests, examinations, or consultations to determine the appropriate action.
The specialist provides specialized care to the patient based on their expertise. This may include treatments, procedures, or therapies tailored to the patient's condition.
The specialist communicates their findings and recommendations back to the PCP. This ensures that the PCP remains involved in the patient's treatment and maintains a comprehensive view of their healthcare.
The PCP and specialist collaborate to develop a coordinated care plan for the patient. This may involve ongoing consultations, follow-up appointments, or adjustments to the treatment plan as needed.
The involvement of the PCP throughout the referral process helps ensure appropriate and coordinated care, allowing individuals to access specialized healthcare services when necessary while maintaining the involvement of their primary care physician.
Failure to obtain a referral when required may result in higher out-of-pocket costs or denial of coverage for specialist visits. In fact claims are denied if a referral is not found attached to the claim while submission.
Now, the above is a very noble intent to keep the PCP involved throughout the process, thereby making the PCP the quarterback to the member’s overall health.
In reality, there are two versions of what really happens:
Version 1:
When a member comes for a visit to the PCP, and the PCP decides a specialist is needed, the PCP suggests the “area of expertise” that needs to look into your concern.
They ask if you have anyone in mind, and if not, they have a few recommendations of specialists they have worked with in the past, and will ask you to setup an appointment with that specialist. In a few cases, the nurse or the back-office manager helps set up the appointment as well.
Once we select the specialist and an appointment is made, a referral note is sent to the specialist.
The specialist has the necessary documentation to bill the insurance company for services performed, and everyone goes on their merry way.
When the member comes back to the PCP next, the PCP follows up on how the appointment went and gets more information.
Version 2:
The member develops a rash and realizes they need to see a dermatologist.
They are aware that their provider is a PCP and not a dermatologist. After consulting with friends and family, as well as conducting online research on their symptoms, they confirm their need for a dermatologist.
However, making another appointment with their PCP just to obtain a referral would be too time-consuming. Therefore, they decide to directly book an appointment with the dermatologist and receive the necessary services.
The dermatologist then informs the member that they require a referral for billing purposes. The member contacts the PCP's office and requests a referral for the dermatologist.
The front office staff records the necessary details and sends the referral (after getting consent from the PCP) to the dermatologist, providing all the information required to bill the insurance company.
From the PCP’s side, their responsibility ends there, and rightfully so. Once the billing is complete, the PCP typically does not follow up on the appointment. And that's the end of the process.
Sometimes a referral never reaches the specialist, and the specialist will continue with billing hoping it goes through. But, the claim gets denied and now the drama of phone tag starts. The specialist’s billing department calls the member they have not received a referral and the member has to either get a referral or pay the balance out of pocket. Member panics, and starts hounding the PCP’s office to get a referral sent out. Member also calls the health plan telling them that the referral should be on the way. The claims adjuster on the plan side says the referral can be back dated if its not in the system, and calls the provider’s office to send the referral via phone instead of an online portal that is typically used. Then a series of follow up’s happen between the member, health plan’s claims department, the specialist’s office and the PCP’s office. While all this is happenning the are bills that start coming to the member’s home for outstanding balance…causing member frustration and an overall negative experience.
Now … was all this necessary?
The member has decided they need to go to a specialist, and one way or the other it is going to happen. A smart member would make sure the specialist is in network so they dont have to pay outrageous fees. Most members within the US Healthcare system are reasonably smart in selecting in-network providers.
If the intent is to keep the PCP in the loop, would it not be enough if we ask the specialist to send details of the services performed to the PCP and close the loop, after getting consent from the member at the time of service? Why are we asking the PCP to give a referral if we already made up our mind, and make them more of a paper pusher. Who is really benefiting from this process?
What if we just did this ?
Member: Hey Doc, I think I need to see a dermatologist.
Doc: Sure thing, let's go over the current issue. If you still want to go ahead, here are a few dermatologists I think you should check out.
Member: But what about Dr. Y? My friends have raved about them, and they're also in my network.
Doc: Yeah, if you've done your homework and feel confident, go for it. Keep me posted on how it goes.
Member: (Meets Dr. Y and gets treated.) Hey Dr. Y, my primary care physician is Dr. X. Can you make sure to send my medical records to them? That way, Dr. X will be up to date on everything I'm doing for my health.
Dr. Y: Absolutely, no problem.
[Next appointment with PCP]
Dr. X: So, how did the appointment go?
Member: It went really well, and I'm feeling good too. I asked them to send the medical records back to you. Did you get them?
Dr. X: Not yet, have I got your permission to fetch the records from their electronic medical system?
Member: Yes, please go ahead.
Dr. X: (looking at the records) Awesome, I'm glad you're satisfied with the experience.
TL,DR:
While intended to ensure coordinated and comprehensive care, the referral process in HMO plans often encounters real-world challenges. The traditional pathway, which hinges heavily on the PCP's involvement, can sometimes lead to inefficiencies, delays, and patient frustration, especially when referrals are more procedural than practical. There is a need for a more streamlined approach that respects the patient's autonomy and time, while still maintaining the critical role of the PCP in overseeing overall healthcare. By simplifying the referral process and enhancing direct communication between specialists and PCPs, the healthcare system can potentially improve efficiency, reduce administrative burdens, and most importantly, enhance patient experience and satisfaction. This evolution in the referral process could signify a significant step towards a more patient-centric and efficient healthcare system.