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Old 07-25-2009, 01:01 PM
 
2,742 posts, read 4,990,578 times
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Quote:
Originally Posted by Pikantari View Post
I am not speaking of an insurance referral. I am speaking of being referred by another physician. I am speaking of, whether or not you have hmo, ppo, or are self employed.
If a particular doctor request a referral even if they have PPO, that is a personal request. And NOT because of PPO.
Meaning that the particular doctor for some reason wants a referral. The insurance company will pay him with or without a referral (if you have a PPO if you have a HMO then without a referral the insurance company wont pay)

Quote:
I am speaking of the instance where lets just say you have PPO and make it simple. You are at a routine follow up and your dr is asking you questions.

You end up having a problem that he cannot help you with, or maybe he can help you but would rather send you to a specialist.
First I would have gone to the specialist from the beginning especially if I have and actually have an PPO.



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He may call or his staff may call the other physicians office.
Sometimes, but I never done it.


Quote:
He will either call the Endo's office himself or have a staff member do it for him.
Nope, if he has a PPO I dont need to, I would just tell him call one that accepts your plan, the only thing I give him is a referral so that the specialist let me know the follow up. But a lot of my Pt. go to the Endo without seeing me first. They just go, and come the clinic for other stuff. So my referral for them(PPO) is not a requirement.


Quote:
This is called a referral. Your doctor has now referred you to another physician for further care.
Really? WOW I never knew that.


Quote:
Has not a thing to do with insurance.
This is where you are wrong, if the Pt. has HMO, the doctor has to approve the referral and in some cases have to make the appointment. If the Pt. has an PPO, he never needs one.


Quote:
Physician referral vs. Insurance referral.
PPO, dont need any type of referral to go to a specialist.
A lot of my Pt. go to specialist without even telling me, and without a referral, unless they are HMO.

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You have a PPO plan. The dr has his secretary call the other office and set you up for a vision screening.
No the doctor DOESN'T have to call nobody. The Pt. can call and make the appointment when they want.


Quote:
In six months, you are in his office and he tells you it is time for another visual field test. Once again, the other drs office is called and the appointment is scheduled.
If you have a PPO, you dont need the referral.

I dont get it, did you even read your copy/paste?

Quote:
Health Maintenance Organization. You have a primary care physician who sees you for your medical needs and if you are having a problem which requires a specialist he will refer you to one.
HMO, requires a referral, plain and simple.

Quote:
The specialist has to be within your plan or it may cost you more money. Your dr will have to either fax over a paper referral prior to your visit, or do it online if your insurance offers it. Just like with any insurance, you may need prior authorization for certain medications or radiological services or hospital stays.
This is HMO. referral is needed.

Quote:
PPO = Preferred Provider Organization. This is the type of insurance which does not require you to have a referral to see a specialist. If your doctor is wanting to send you to another physician he needs to make sure they are in your network.
Ok, lets read it again, "does not require you to have a referral to see a specialist."
So even by your own copy/paste you can clearly see that with a PPO you dont need any type of referral.
That is why the company has sent you a think book called directory, with all the network doctors with that insurance. You can call any of them to make an appointment without the need to see a primary doctor (Peds, I.M. or F.M.)

Quote:
Well then, you can feel my pain. I had a PPO and I have Epilepsy. I moved from another state and needed a new Neurologist. I called several and each one said my doctor needed to call to make the appointment. I don't have a doctor, I tell them.

I am sorry, but we cannot help you. You'll have to get your dr to call the office.
You should have called your insurance company and told them of this, that could be and I am pretty sure it is againts their contract for PPO.

Quote:
I am told back in May that there are no openings til July. I finally got an appointment. It is in September. So, I had to go to their walk in clinic to get referred. Still not HMO yet.
Why you didn't call your insurance company? You are paying or your employer is paying for a PPO which is more expensive for a reason (and other reasons also).

Quote:
I am told back in May that there are no openings til July. I finally got an appointment. It is in September. So, I had to go to their walk in clinic to get referred. Still not HMO yet.
Call the insurance company and informed them of this, they would tell you if you actually need or don't need a referral especially when you had an PPO. Then call the office and tell them that is in their contract that they hae to see you without a referral.

Quote:
Do you call and schedule the appointment for them? This is called a physician referral.
No, my MA only do referrals for HMO/Medicaid Pt. All other PPO, don't need one, they can call and make the appointment when they want to (and if they want to).


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Old 07-25-2009, 04:04 PM
 
Location: NoVa
17,895 posts, read 17,387,540 times
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Quote:
Originally Posted by cjma79 View Post
If a particular doctor request a referral even if they have PPO, that is a personal request. And NOT because of PPO.
Meaning that the particular doctor for some reason wants a referral. The insurance company will pay him with or without a referral (if you have a PPO if you have a HMO then without a referral the insurance company wont pay)

A physician referral, not an insurancer eferral.

First I would have gone to the specialist from the beginning especially if I have and actually have an PPO.

If you are someone who cannot dx themselves, how would you know what specialist to go to?

If you have no idea what the symptoms you are having mean, where do you go?

Do you just pick one and go from there, if it does not correlate with your symptoms go to the next one?

How does the public know?


Sometimes, but I never done it.


Nope, if he has a PPO I dont need to, I would just tell him call one that accepts your plan, the only thing I give him is a referral so that the specialist let me know the follow up. But a lot of my Pt. go to the Endo without seeing me first. They just go, and come the clinic for other stuff. So my referral for them(PPO) is not a requirement.

No, you don't need to. I suppose the doctors I worked for found it to be going the extra step to have us call for the patients. Patient checks out and needs to see another dr.

Oh hello Mr. Patient. I see here you need to see an Endocrinologist. Good luck finding one on your own. Wanna borrow the yellow pages?

No. How does the elderly patient know she needs to go? Does she even know what an endo is?

No. I used to have Tuesdays as my half day off. There was this one older lady, I guess she was in her 80's. She lived in an assisted living facility and was only comfortable driving around town.

She was very upset learning about this dx, and then even more upset wondering how she will ever get to this new dr.

I made sure to schedule all of her appointments on Tuesdays that were not for the dr I worked for. I picked her up and I took her three towns over to her appointments. Not only did I schedule them for her but I drove her there.

Did I expect her to call and schedule it? No. Did the dr I worked for expect me to do it even though she has Medicare which is a PPO? No. He expected me to do it and that is what I did.

it was my choice to got he extra step of taking her.

Really? WOW I never knew that.


This is where you are wrong, if the Pt. has HMO, the doctor has to approve the referral and in some cases have to make the appointment. If the Pt. has an PPO, he never needs one.

I know this. This is why I speak of the physician referral vs. the insurance referral.

I have no idea where you practice but I do not know why you just cannot understand that in the area in which I live it does not matter what kind of insurance you have. A specialist office will not schedule an appointment for a patient as a first time patient. Your dr has to do it. I do not know any other way to explain that to you.


PPO, dont need any type of referral to go to a specialist.
A lot of my Pt. go to specialist without even telling me, and without a referral, unless they are HMO.

No the doctor DOESN'T have to call nobody. The Pt. can call and make the appointment when they want.

OMG I wish I had you sitting next to me so we could call a specialist office and try and make a new patient appt. If it is for a return visit that is fine, call all day and they will do it. Not for a new patient appt.


If you have a PPO, you dont need the referral.

I dont get it, did you even read your copy/paste?

I never did a copy/paste. What are you talking about?

HMO, requires a referral, plain and simple.

This is HMO. referral is needed.

Ok, lets read it again, "does not require you to have a referral to see a specialist."
So even by your own copy/paste you can clearly see that with a PPO you dont need any type of referral.
That is why the company has sent you a think book called directory, with all the network doctors with that insurance. You can call any of them to make an appointment without the need to see a primary doctor (Peds, I.M. or F.M.)

I did not copy and paste anything. That is the knowledge I have(short version) of the two types of insurances. You asked me what each one was and I told you. Why do I need to copy and paste crap?

You should have called your insurance company and told them of this, that could be and I am pretty sure it is againts their contract for PPO.

Why you didn't call your insurance company? You are paying or your employer is paying for a PPO which is more expensive for a reason (and other reasons also).

Call the insurance company and informed them of this, they would tell you if you actually need or don't need a referral especially when you had an PPO. Then call the office and tell them that is in their contract that they hae to see you without a referral.

No, my MA only do referrals for HMO/Medicaid Pt. All other PPO, don't need one, they can call and make the appointment when they want to (and if they want to).


If you are truly a doctor my question to you is this: Do you do anything for your patients? Does your staff do anything for them? What gives?

Do you ever think they need to see someone other than you? Do you expect them to know why they need to see and do it themselves?

: smack::s mack::sm ack::sma ck::smac k::smack : : smack::s mack::sm ack::sma ck:
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Old 07-25-2009, 06:18 PM
 
2,742 posts, read 4,990,578 times
Reputation: 487

Quote:
A physician referral, not an insurancer eferral.
It doesnt matter... PPO you dont ANY type of referral.



Quote:
If you are someone who cannot dx themselves, how would you know what specialist to go to?
If you have GI, problem, you can go to a GI, well not now that you have HMO now, if you still had a PPO, and you had a GI problem you could have gone to the Gastro. without referral. If you have a skin rash or a skin disease you can go to a derm without a referral.

Quote:
If you have no idea what the symptoms you are having mean, where do you go?
Well in this case you go the primary.

Quote:
Do you just pick one and go from there, if it does not correlate with your symptoms go to the next one?

How does the public know?
If the public doesn't now they go to the primary, if the person knows at least what it relates to then if they have a PPO they can go to the specialist. Rarely I see a Pt. with PPO that don't know which specialist they need to see.



Quote:
No, you don't need to. I suppose the doctors I worked for found it to be going the extra step to have us call for the patients. Patient checks out and needs to see another dr.
No I don't need to. If your Dr. like to do it for them maybe is a way to keep the Pt coming back, and extra service.


Quote:
Oh hello Mr. Patient. I see here you need to see an Endocrinologist. Good luck finding one on your own. Wanna borrow the yellow pages?
Every person that has a PPO, should have received the providers directory. I see you know little about insurance.


Quote:
No. How does the elderly patient know she needs to go? Does she even know what an endo is?
If the Pt. request help the MA would do the referral.

Quote:
I made sure to schedule all of her appointments on Tuesdays that were not for the dr I worked for. I picked her up and I took her three towns over to her appointments. Not only did I schedule them for her but I drove her there.
That was nice, but it was not a requirement.



Quote:
Did I expect her to call and schedule it? No. Did the dr I worked for expect me to do it even though she has Medicare which is a PPO? No. He expected me to do it and that is what I did.
If your doctor wanted to you drive her also, you should be paid for extra work.

Quote:
it was my choice to got he extra step of taking her.
Like I said, it was nice.



Quote:
I know this. This is why I speak of the physician referral vs. the insurance referral.
A PPO pt, doesn't need any type of referral, what so ever.
Lets say a Pt. has constipation for 5 days, if he has a PPO, he can just go to any GI that belongs to his network, without any referral.
Let me say that again, without any type of referral, without even seen me or any other primary care.


Quote:
I have no idea where you practice but I do not know why you just cannot understand that in the area in which I live it does not matter what kind of insurance you have. A specialist office will not schedule an appointment for a patient as a first time patient. Your dr has to do it. I do not know any other way to explain that to you.
I have worked in Florida and NY, I know that it can't be because I understand what a PPO means, and I have read PPO, HMO contracts.



Quote:
OMG I wish I had you sitting next to me so we could call a specialist office and try and make a new patient appt. If it is for a return visit that is fine, call all day and they will do it. Not for a new patient appt.
Sure lets do this, tell me in what city, what insurance company with PPO, I would look someone from the network, act like a Pt without referral and make an appointment (of course I am going to cancel the appointment.)


Quote:
I did not copy and paste anything. That is the knowledge I have(short version) of the two types of insurances. You asked me what each one was and I told you. Why do I need to copy and paste crap?
Well then from your own knowledge you have said they don't need a referral.



Quote:
If you are truly a doctor my question to you is this: Do you do anything for your patients? Does your staff do anything for them? What gives?
I do everything a doctor should do, Dx, treat (Rx), inform and follow up.
The MA do all the required referral for HMO/Medicaid, as the contract state. Also when I referral(PPO), the MA usually tells the Pt. which doctors I prefer (friends) and a tel. number is provided, but at the end of the day, they call which ever doctor they want.

Quote:
Do you ever think they need to see someone other than you? Do you expect them to know why they need to see and do it themselves?
I don't get it, do you think Pt. are stupid or something?
So if I refer a Pt. to the Heme/onc they don't understand me?
That would be the first for me.
Unless there is a language barrier, I never had a problem referring Pt. to specialist. I say you need a referral to Heme/Onc, they say Oh the blood doctor or the cancer doctor. If more help needed that the nurse or the MA would explain further what type of doctor they need.


Do you really think they don't know which doctor they need to see?
Once I tell them which specialist to see, I am pretty sure they know where to go. They are not babies that need someone to make appointment for them. They leave the clinic with a paper saying which specialist to see.
When they go home they can do any appointment they want.
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Old 07-25-2009, 06:35 PM
 
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It sounds to me that you think the doctor should do everything for the Pt.
Drive them everywhere, maybe even pay for Rx maybe.
Maybe I should post papers on the clinic saying if they need any type of help, including social help, dating services, they can call me.
The doctor diagnose the Pt., treats the Pt. informs the Pt. of the treatment, and diagnose and with his best ability help the Pt and when is out of his normal practice referral the Pt to a specialist.
If the Pt. has an HMO the doctors office or clinic would do the referral and sometimes the actual appointment. If the Pt. has a PPO, he LEAVES the clinic with a paper saying which specialist they need, a note for the specialist, my contact information for follow up, that is IT.
When the Pt. goes home they can pick up their insurance directory or go online (most insurance would have the directory online) and look for the closest doctor, or they can call the specialist that I recommended (or the MA). That is it, from this point on the Pt. does what ever he wants, he can come back to me or go to the specialist.
Why is this so difficult to understand.
PPO, you can go to the specialist without a referral from the doctor.
HMO you need referral from the doctor.
A referral is a referral no difference, so lets not invent new difference between medical referral and insurance referral.
Both Pt receives the same referral, one Pt need approval while the other don't. Even some HMO don't require the clinic to do the appointment once they have to GO for the specialist they can pick any specialist form the network without us making any appointment.
Our MA only makes appointments only when needed, when Pt. cant do it themselves (for any reason), or is actually requires because of their insurance. We don't even do the referral for Medicaid/HMO unless the Pt request it. So I really don't understand what you are talking about.
Here HMO like Fidelis, AmeriGroup, Health Plus, Health Choice, etc only need referral, they don't need us to make them the appointment, only the referral.
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Old 07-25-2009, 07:13 PM
 
Location: NoVa
17,895 posts, read 17,387,540 times
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OK, whatever. I do know about insurance. I do go the extra step for patients. I normally work with the elderly and I treat them how I would want to be treated or how I would want my grandmother or mother or father treated.

Greenville North Carolina. 252.752.6101

Dr. Alloway. You are a new Patient with RA.
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Old 07-26-2009, 08:36 AM
 
2,742 posts, read 4,990,578 times
Reputation: 487
Quote:
Originally Posted by Pikantari View Post
OK, whatever. I do know about insurance. I do go the extra step for patients. I normally work with the elderly and I treat them how I would want to be treated or how I would want my grandmother or mother or father treated.

Greenville North Carolina. 252.752.6101

Dr. Alloway. You are a new Patient with RA.
Mod cut: recommendations from members with more than 10 posts are permitted, as lon as the members are NOT recommending themselves, which would constitute advertising.
I was only asking for insurance company name (with a PPO plan so that I can look up the directory for that plan in your area), and where you live (just the town or city or area).
Not the private phone number a of private office.

Last edited by Viralmd; 07-26-2009 at 09:15 AM.. Reason: Mod cut: mods will give direction if something is not within the TOS
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Old 07-26-2009, 08:55 AM
 
2,742 posts, read 4,990,578 times
Reputation: 487
Since today is sunday, and all or most of all private office are closed I called Pitt county memorial hospital and made an appointment for rheumatology, without any problem (at the end I cancel the appointment), they only asked for DOB, Name, Address (I search google for a fake address), and insurance company I said Aetna PPO, never ask for a referral.
On monday I will call your provider and do the same.
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Old 07-26-2009, 10:06 AM
 
Location: NoVa
17,895 posts, read 17,387,540 times
Reputation: 18058
I'll have to do the same. I have never scheduled at a public office, only a private practice. Always been told the same thing. Your dr needs to call us.

Have a nice Sunday.
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