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The Primary Care Physician (PCP) Referral

Written by employeebenefits  |  24. September 2000

If you are like many Long Islanders, your companies' health plan offering is one of the many HMO carriers available in this marketplace. Whatever your views on managed care are there seems to be a common dislike for one particular aspect of HMO coverage; the all important doctor referral. In most cases the referral is when you must get a written referral from your designated primary-care physician (or gatekeeper as they are sometimes called) to see a specialist in your plans provider directory. While their can be problems with this process it has been my experience that there is more misinformation about this process that causes a perception of trouble with the referrals in general. First, it may help to understand why managed care carriers require this step. Since HMO's try to promote prevention through preventative care they feel that requiring a member to develop a relationship with a general practitioner will ultimately benefit both the member and carrier. It was designed to prevent members from ping-ponging through the medical system that was prevalent in the fee-for-service system. Second, 99% percent of all referrals are approved without any problems. Most members will never experience a problem getting a referral to see a specialist. It is also important to know that carriers offer a version of their plans that do not require the referral process. These plans are a little bit more expensive that their referral required counterparts however, it has been my experience that this variation is very popular. If your current plan requires a referral and you would like to switch then contact your companies human resources department and inquirer about the availability of such a design. If your company does not offer this plan feature then there is not much you can do however, if enough of your counterparts are asking they will have to look into it. If you have any questions regarding employee benefits you can email me at karmstro@optonline.net.

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