HMO/Managed Care
HMO insurance mindset
Health Maintenance Organizations are a unique way to insure large groups of people. Basically, the insurance company, a group of patients, a hospital and a primary care doctor all agree to "manage" the health care of the group of patients in a cost-effective manner. There are advantages and disadvantages to this approach.
HMO plans require the patients to choose a primary care doctor within the network that the patient wants to get his/her health care. I'm affiliated with the Ascension Genesys HMO network, so choosing me as your primary care doctor means that you choose Ascension Genesys Emergency Department, Ascension Genesys Hospital, and Ascension Genesys specialist network. There are HMO networks all over Michigan, so if you prefer to use a specialist, hospital or emergency room in another network (McLaren, Beaumont, U of M) you would have to either change to a PPO type insurance to keep me as your primary, or change to a primary care doctor within the network you want to utilize. Here’s the thing: people get sick. People get sick with horrible things like cancer and heart disease. If you got sick with cancer or heart disease and have an HMO, you’d have 2 options. You could use the Ascension Genesys cancer or heart team (both which have my FULL confidence) or you could find a different primary care doctor. I can’t state this any more clearly. I only refer HMO patients to Ascension Genesys in-network providers. Here is another way of stating this: I do not authorize out-of-network referrals.
HMO plans also require patients AND doctors to be flexible and available to each other. You CANNOT go directly to an urgent care without first calling my office for an appointment or advice, unless there is a life, limb or vision threatening concern. We have recently (Jan 2019) majorly changed the way we schedule urgent care visits so that I could be more available. This means that if you have to work at your job until 6pm every day and can never make it to my office for urgent care appointments, you should switch to a PPO type insurance that allows use of after hours. If you regularly use after hours without calling the office first, you will be discharged from the practice.
The best analogy I can think of is that an HMO plan is like a bus pass compared to a PPO plan being like an Uber. With an HMO, the employer and the patient will save costs on insurance (bus passes are less expensive). The cost savings comes because the bus driver (Dr. Zerafa) guides his patients on the most efficient route to health care determined by the HMO (which would be like the bus company). If you are ok with staying on the bus route, this can be a good option. If you want to go exactly where you want, exactly when you want, paying extra for an Uber might be a better choice. You would never buy a bus pass, get on the bus, then ask the bus driver to drive off the route right? In fact, that would put the bus driver in a pretty awkward position. The same thing applies to HMO insurance. If you prefer to go directly to your destination, especially one that is outside of the Ascension Genesys network, it might be worth it to invest in a PPO type of insurance.
-Dr. Zerafa
Referrals
If you have an issue (for example, a skin problem, joint pains, migraine headaches, etc.) call my office so that I can evaluate you. I may be able to treat you here, or I may refer you to an in-network provider that I trust. I need to evaluate all problems first here in my office.
The referral process is complex and time intensive. We have employees that full time work with insurance companies, specialists and imaging centers to help you get the care that I recommend. This can be a long and tedious process. A single referral might require 45-60 minutes of my office and me documenting why I ordered that referral and trying to get your insurance company to approve my decision, BEFORE we can even call the specialist office or imaging center to schedule you. Most insurance companies contract out a company whose job it is do deny any referral and put a burden on my office and me to justify my medical decisions. Be patient with the referral process.
I do not refer patients to chiropractors. Obviously, you could go to a chiropractor and cash pay. You could use your insurance if it does not require a referral.