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Monthly Archives: January 2012

Accessing Specialty Care: Are you Covered?

It’s time to see a specialist. Will your health plan cover it? And how much will they pay? These questions are pretty familiar to most of us. Many people end up either getting care they thought was covered and then getting hit with a big bill, or spending so much time getting the right referrals and authorizations that they give up.

How can you avoid these two situations? A little bit of homework and a few phone calls may be all you need.

Step One is finding out what type of plan you have: HMO, PPO, or POS? This will tell you how to navigate physician networks and referrals.

-    If you have an HMO, you’ll need to get a referral from your Primary Care Physician (PCP) before you can get care from any specialist.

-    If you have a PPO, you can go to any specialist you like without a referral. However, if you see an in-network provider, your plan will pay a bigger portion of the bill. For example, your share might be 20% for an in-network specialist but 50% out-of-network.

-    If you have a POS plan, you do not have to have a PCP, but if you do, he or she can refer you to both in-network and out-of-network providers. You do have the option to go out-of-network without a referral, but you would pay more. POS plans are basically a hybrid between HMOs and PPOs.


Step Two is finding a provider. Now that you know what type of plan you have, you know whether you need a referral to see any kind of specialist. Your PCP might be able to give you referrals, but it’s your job to make sure that the physician is part of the plan’s network.

Asking the question “What providers are covered?” will usually get you farther than the question “What type of specialist is covered?” This gets back to the importance of your plan’s network. Let’s say you need to see an allergist. Your plan can’t say whether it always or never covers allergy testing, only whether it covers a certain allergist.

If you don’t already have a specialist in mind, start with the plan’s website, where you can usually filter your provider search by specialty. If you don’t see what you need, find out what Physician Groups or Medical Groups the plan works with. This will usually be in your Summary of Benefits or you can call the plan to ask. Then try searching on the Physician Group’s website. Sometimes this gives you more current information than going through the health plan.


Step Three is calling the provider. Once you’ve found a provider you want to see, it’s always a good idea to call them to make sure they take your plan, even if the homework you did in Step Two says they do. Doctors can join and leave networks at any time so the plan’s information may not be up to date.

Ask about the specific name of your plan, not just the insurance company—for example “The Purple Preferred PPO” rather than “Blue Cross”. Providers might accept some Blue Cross plans, but not all of them.

Step Four is finding out the rules before you get the care. Often times, the physician’s office staff can help you with this. Before you leave the office, ask them to check on coverage for tests and procedures that your doctor has prescribed. This is also a good time to ask about coverage for other needs like medical equipment, prescription drugs, or additional referrals and authorizations. These staff are often more familiar with the language and have the specific medical codes to get more exact answers than you might be able to on your own.