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From "Scribbles", a Lake Shore Pediatrics publication, Winter 1998 How well do you know your health insurance plan? Do you know what services it covers, and specifically, what it does not cover? Do you have your choice of primary care doctors? Can you see a specialist without plan approval? In an emergency, do you know which urgent-care facility is covered by your insurance? Managed care plans, such as health maintenance organizations (HMOs), preferred provider organizations (PPOs) and point of service plans (POSs) have brought these and other important questions to the foreground. Managed care is a growing trend in the United States among employers who want to offer employee healthcare coverage, but need a more cost-effective way to do so. Managed care plans contract with physicians and hospitals to offer services at a set price, thereby helping to curb healthcare costs. Managed care plans also establish a "gatekeeper" system to ensure that health care services are used appropriately. Keep in mind that managed care plans try to keep costs down by requiring your primary care doctor, like your pediatrician, to take more control over the types of health care services you receive. Under a managed care system, your pediatrician's role as a caregiver is much the same as it always has been - provide preventative care, treat your child for illnesses and injuries, diagnose and treat acute and chronic disorders, and when needed, refer or coordinate other services for the total care of your child. What has changed with the advent of managed care, however, is the pediatrician's new role as "gatekeeper." Your pediatrician may now be responsible for authorization of certain services, special visits, after-hours care, or emergency services. For example, many plans now require your primary care physician to obtain authorization for referrals to specialists prior to your visit. The subspecialist may not see you without authorization. This approval may take a week for us to obtain. Also, many plans require approval for hospital procedures (i.e. MRI, CT scans), outpatient and inpatient surgery, and hospital stays. Without physician and plan approval, you may find these services and fees will not be covered. The end result is that you may have to pay for them yourself. There are plans which do not allow us to issue a referral after the visit. It is also extremely important to understand the coverage of emergency and follow-up care. Know how your plan defines a true emergency, and how it differs from an acute injury or illness. This is particularly important in the event you are out-of-town, or for college-age children who are covered on your plan, but live away at school. "The best advice we can offer our patient families is to take time and get to know your insurance plan," says Linda Gunderson, Office Manager for Lake Shore Pediatrics. "When you are offered a choice of plans, it helps to do your homework and know what plan covers which services. Although we are happy to help answer your questions, your employer, or plan manager, is the best candidate to answer specific questions regarding your particular managed care plan," says Linda. Advice on Insurance If you are covered by a managed care plan, (HMO, PPO, POS), here are a few helpful reminders to make your next LSP visit a smooth one:
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