Health Maintenance Organization, or HMO, plans are the typically the least expensive of full coverage medical insurance plans. The low premiums are a result of tightly managed care. This managing of care often leads to issues and dissatisfaction with members of the HMO plan and the providers within the HMO network. HMO managed care principles include a gatekeeper model, pre-authorization requirements, provider network and closely reviewed decisions made on services requested and received. These practices, while contributing to cost containment and lower premiums, lead to issues and members seeking alternative plans and providers opting out of network participation.
Gatekeeper/Referral Model
The gatekeeper model is the hallmark of the HMO plan. HMO plans require their members to first utilize a primary care physician for all services. A referral must be obtained from the primary care physician prior to visiting a specialist. Many HMO members take issue with this process as they find it a laborious and bureaucratic practice that increases the length of time to see a specialist.
Pre-authorization Requirement
Most outpatient or inpatient procedures, surgeries, hospital stays, specialty medication and other services require pre-authorization from the HMO. The patient is responsible for obtaining authorization prior to accessing these services. If services are not pre-authorized, payment is often denied and the patient is responsible for the bill. This leads to many claims issues from both patients and the providers that service them.
Provider Network Issues
Participating in an HMO plan means that the member is limited to using providers, hospitals and pharmacies within a HMO network. The HMO contracts with providers to participate in their network. HMO members can only visit providers within the HMO network or the out-of-network doctor visits and associated services will not be covered by the insurance plan. This presents an issue in rural areas or if the member is not satisfied with the providers in the HMO network. In addition, providers may be dissatisfied with the typically lower network reimbursement fees which dictate the fees they will receive for each billed service.
Denial of Care
Requests for medical services are closely reviewed by a team of clinical professionals that work for the HMO. HMO members take issue with this as they feel this creates a conflict of interest as these decisions may be biased in favor of the HMO and based on dollars and not necessity of care. Though there is often an appeal process, care decisions are ultimately held by the HMO or a third party contracted by the HMO.
Tags: within network, care physician, closely reviewed, gatekeeper model, issue with, issue with this, managed care