I am a provider on most PPO plans in this area and currently have limited availability on certain HMO plans for reasons stated in the following excerpt regarding insurance types. Keep in mind, however, that most if not all PPO plans will cover visits and treatment with “out-of-network” physicians should you not find my name on your insurance physician panel. “Out-of-network” visits are usually associated with different co-pays and deductibles.

Questions About Eligibility

Should you have any questions regarding your ability to be seen in our office, please call us and inquire. Insurance issues are often terribly confusing, and we are almost always able to provide answers to our patients’ questions. Additionally, we are happy to bill your insurance for you for care provided by our office.

Evaluation / Treatment When Not Eligible

If you would still like to see me and I am not on your insurance plan, cash, check, or credit cards are accepted. Affordable payment plans are available as needed.

Explanation of Insurance Types

Perhaps background on the distinction between insurance plans will help you if you are considering changing your current coverage benefits for you and your family.

There are currently two major types of health plans: HMO (Health Maintenance Organizations) and PPO (Preferred Provider Organizations) with its alphabetical cousins, POS (Point of Service) and EPO (Exclusive Provider Organization).

HMO  (Health Maintenance Organizations)

This type of coverage places your primary care physician (PCP) as the “gatekeeper,” who must approve referral to specialists. This approval process requires that your PCP completes forms subject to the approval of the HMO. Your PCP is limited to referring to the panel of specialists commonly referred to as in-network specialists. In-network specialists agree to deeply discounted fees in return for these referrals. Your already overworked PCP is often inundated with referral paperwork.

The PCP is also graded by your health plan based on the number of specialty referrals that are made. As a result, additional pressure is placed on your PCP when they must refer a patient. PCPs with an inordinately high rate of referrals may be penalized or even dropped from an insurance plan.

Once at the specialist’s office, authorization hurdles must again be navigated. Your specialist is often handcuffed in treatment options based on decisions made by the HMO management.

The advantage to you, the patient of an HMO, is often lower premiums and lower co-pays, although if you go to a specialist who is out of network, the HMO is not obligated to pay for your care. You also have limited geographic coverage, except in emergency situations.

Due to these deeply discounted fees, specialists must often limit the appointment availability, effectively limiting your access to appropriate care.

PPO  (Preferred Provider Organizations)

This type of coverage does not employ the PCP gatekeeper approach. Your PCP answers only to you and not an insurance company bureaucratic panel. While you will continue to rely on your PCP for when to see a specialist, your treatment is virtually unimpeded. You will still have affordable co-pays. The insurance premiums might be slightly higher, but consider the advantages noted below.

  • Self-referral to most specialists.
  • Quicker access to top specialists.
  • Reduction of paperwork and authorization hassles.
  • Minimal interference in the physician-patient relationship.

Reducing the paperwork reduces our administrative costs so that we can focus on providing you with better health care. This is really about a physician-patient relationship. My goal is to provide you with the very best in health care options. You deserve that.

I would encourage you to select your health care coverage very carefully. While your human resources department or insurance professional will be best able to discuss your plan specifics, my office staff would be happy to assist you in any way we can.

Please feel free to call Jessica or Jody in our office. They will be available to assist you in finding the best health care coverage for you.