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Health insurance is a rapidly changing tangle of mergers, acquisitions and acronyms. Finding the plan that is best for you is often frustrating and confusing. Understanding and following the guidelines or rules of your plan can also be a difficult undertaking. With insurance companies changing their names and products frequently, it is little wonder that the policyholder finds the insurance maze one they would like to avoid.
Take a look ...
Alphabet Soup — PCP, HMO, PPO, EPO or POS
PCP (Primary Care Provider) — A physician chosen by the patient who directs the patients care by either providing it or by referral to a specialist.
HMO (A Health Maintenance Organization) — A plan in which each patient chooses a PCP. They usually have a small co-payment for a visit to their doctor, and need a referral if consultation or treatment is needed from anyone other than their PCP.
PPO (Preferred Provider Organization) — A plan that allows the patient to see any physician in the network. There is no PCP and a referral is not necessary to seek care from a specialist. Patients usually have a small co-pay, but may also be responsible for a deductible.
EPO (Exclusive Provider Organization) — A plan that is essentially the same as a HMO.
POS (Point Of Service) — This plan works like an HMO, but the patient can see any doctor of their choice. If they see their PCP the cost is minimal if they choose to select another doctor, the benefits paid by insurance are lower and the patient is held responsible for a larger co-insurance payment.
An Indemnity Plan is a plan that allows patients to seek care from any physician. This type of insurance usually has a deductible and 20-30% co-insurance, which is the patients responsibility.
Referrals — What You Should Know
A referral is necessary when you are experiencing a condition or problem that is not treatable by a PCP. Your PCP will then request an authorization from your insurance company for you to obtain health care by another provider. Most referrals are finalized in two to five days but some may require additional information or approval by the insurance company medical director. It is generally advisable to not make an appointment with a specialist until you have seen your PCP and obtained a referral or your insurance plan may not pay for your visit. Insurance companies also sometimes deny referrals for lack of medical necessity, even if your PCP requests it.
Longmont Clinic is a multi-specialty practice, which means there are many individual physicians who practice in several medical specialties all under one roof. Our physicians participate in many different types of insurance plans, HMO's, PPO's, EPO's etc. The type of insurance plan you have dictates whether you need to choose a primary care physician, such as a family medicine doctor or a general internist, or if you can make an appointment directly with a specialist.
If you would like further information on current insurance plans accepted by Longmont Clinic please call a patient representative at 303-776-1234 ext. 6152.
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