Choosing The Right Doctor Will Help You Get The Most Out Of Your HMO! How Your Choice Can Help Or Hurt!

The Advantages of Belonging to a Large Group

Individual health insurance or even family health insurance has limitations. If you already have an HMO, making it work for you can be a challenge. But if you know a few simple things, your HMO can be a breeze to navigate. You want to make the most of your HMO benefits with the least amount of effort on your part. Whether you have Aetna, Humana, Cigna, Anthem, they all work basically the same way.

All of these health insurance plans require you to choose a primary care physician. Most people think that means a general practioner, but literally all HMO policies consider a doctor who is certified in internal medicine or a doctor who is certified in family practice to be primary care physicians. Both of these 'specialties' have more training than a general practitioner. For example, most internists have extensive training in the management of diabetes, cardiac disease, pulmonary disease and hypertension. If you suffer from any of these illnesses, it is probably to your advantage to choose an internist as your primary care physician.

Next, most of the large medical groups are no longer capitated, meaning they no longer receive a set amount of money each month for providing your care. The large groups bill the insurance company on a fee for service basis and that is the best way to go for you. If you join a large group, they do not have an incentive to provide less care than you require. Because they are a large group, they are in a better position to negotiate with the insurance company, so before you pick a doctor who practices out of a small office and has no large group affiliations, think twice. Sure, a small office might feel nostalgic and homey, but getting the actual care you require may be more difficult and take more time.

The large group practices almost always have in-house specialists, and your primary care physician doesn't have to wait for authorization from the insurance company to send you to see the specialist. They will simply send you. By eliminating any waiting period, you may just be saving your life!

Large Groups Do Their Own Utilization Review

Utilization review is an important feature of any HMO policy. If an insurance company believes that certain treatments are medically unnecessary, they will be denied. Then the doctor will have a fight on their hands. They will have to go through the appeals process, often handled and reviewed by a nurse or group of nurses, if you are lucky. Some insurance companies don't even require a nursing degree for an employee to become a utilization review manager. So sometimes, your doctor will be arguing your medical treatment with someone who is not a medical professional.

On the other hand, if you belong to a large group with many members, the large group will have their own utilization review and because they are basically fee for service, the turn around time for authorization is usually decreased and the approval rate is much higher. For example, if your primary care physician has sent you to the in-house neurosurgeon and the neurosurgeon says you need an MRI, the turn around time for authorization can be as little as 24-48 hours. If you are dealing with an independent medical office, the request will go to the insurance company and they have up to 30 days to make a decision. 

Keeping a Buffer Between You and Your Insurance Company

Living in southern California, there are many large groups from which to choose. Most are affiliated with large hospitals and most will accept HMO patients from any insurance company. It is my firm belief that the single-most important thing you can do to make your HMO insurance policy work for you is to choose the correct primary care physician. That choice, above all others, will determine the course your medical care will take. If unhappy with the care you are receiving, your insurance company will almost always allow you to change primary care physicians at least once every month. I do not recommend changing doctors as often as you change clothes, but if you are unhappy with the doctor you have, make a change. Try to find someone you feel comfortable with, someone you feel you can trust, someone you think can save your life, if necessary.

There are rural areas throughout the country where patients have little access to a large medical group or even a large regional hospital. Those patients are less likely to be afforded a real choice when it comes to a primary care physician, but they usually have the choice between a general practitioner or doctor certified in internal medicine. Your doctor must be your buffer between you and your insurance company. Your doctor has the responsibility to fight for you and your health.

Most HMO's offer the same benefits, regardless of what they say. When people report that they have had a bad experience with their HMO, it is usually because their primary care physician has not done his or her job and most patients blame the wrong party.

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Deni Edwards profile image

Deni Edwards 6 years ago from california

Thanks for the information! You covered an important aspect of HMOs based upon large group affiliation that many people don't often consider. It can be extremely important and, sometimes, lifesaving due to the turn-around time on approvals.

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