0

A major difference between HMO and PPO plan is that HMO requires a primary physician's referral before one goes to see a specialist.

In practice, how big of a drawback is this? It does take one extra trip to the doctor office. However, it seems wise to see a doctor who are better than I am at knowing what's necessary anyway. In addition, urgent care is covered no differently between HMO and PPO, so this "drawback" of HMO is not a factor during emergencies when time is valuable.

  • Some practices require a referral to a specialist even if you have a PPO. The specialists are overbooked, so it's a way to keep down the number of appointments. – mkennedy Nov 7 '16 at 2:27
2

Referrals are an inconvenience and a (usually short) delay in treatment... And primary care physicians really dislike being forced to act as the insurance company's gatekeepers.

It also may mean one more copay for the referral session. And theoretically there is the potential that your PCP will tell you that you don't need a specialist... which could be reassuring or worrying depending on how much you trust them.

Up to you whether you are willing to put up with jumping through that hoop or not. Some people really hate the extra step, others haven't found it to be a problem.

  • That's a good point about them refusing to refer. If they do, I can either go to another primary physician for a second opinion, or go to a specialist out of pocket, correct? – Heisenberg Nov 7 '16 at 1:12
  • As I said, it's mostly a matter of convenience. Another copay, scheduling another appointment which may.not be available immediately. If you are uncomfortable or worried, that time may bother you more than you would expect. Or may not. – keshlam Nov 7 '16 at 1:16
  • @Heisenberg - I don't think you can have more than one "primary" physician, and the insurance company could very well choose to not cover something that was referred by someone other than your specified primary physician. As for paying out of pocket- you can absolutely do that, but it might not go towards your deductible/MOOP either. – TTT Nov 7 '16 at 19:53

Your Answer

By clicking “Post Your Answer”, you agree to our terms of service, privacy policy and cookie policy

Not the answer you're looking for? Browse other questions tagged or ask your own question.