and, the HMO I was provided by my former employer paid physicians for NOT giving referrals.
OKAY MIRN, THIS IS PART OF THE WAY HMO'S WORK: DOCTORS ARE PAID A CAPITATED RATE IE: X NUMBER OF DOLLARS PER MEMBER/PER MONTH- THATS ALL.(IF THE PCP HAS 1000 HMO MEMBERS-THE PCP GETS $1000/MONTH) THE HMO DOES NOT PAY THE DOCTOR ANY MORE FOR ORDERING TESTS OR ANYTHING. MOST HMO'S HAVE A "REWARD" PROGRAM WHERE THE PCP GETS A MONETARY BONUS AT THE END OF EACH MONTH FOR KEEPING UTILIZATION(OF HEALTHCARE) LOW...THIS IS NOTHING NEW.
My employer had NO say in this. I know this because at a time when I needed to see a specialist and was denied BY THE HMO, the HR person at the facility worked with me to get the referral I needed. She was unsuccessful, but the employer tried to get me the needed medical care my HMO refused me....MIRN, FIRST OFF YOUR PREVIOUS EMPLOYER DID HAVE A SAY IN THIS- YOUR EMPLOYER WAS THE ONE WHO PURCHASED THE PLAN!!! MOST LIKELY YOUR PREVIOUS EMPLOYER WAS NOT SELF INSURED, HAD THEY BEEN YOUR EMPLOYER COULD HAVE MADE THE HMO MAKE AN EXCEPTION FOR YOU. HOWEVER, SINCE THEY WERE NOT SELF INSURED(IE: THE HMO IS THE ONE WHO PAYS THE CLAIMS)THEY(THE HMO) LEGALLY DO NOT NEED TO MAKE ANY EXCEPTIONS...
AGAIN I SAY THAT IT IS NOT THE HMO- IT IS WHOEVER BUYS THE HMO'S HEALTHCARE PLANS! IF HMO'S AND INSURANCE COMPANIES PAID FOR EVERY MEDICAL CLAIM THEY ENCOUNTERED, THERE WOULD NO LONGER BE ANY HEALTH INSURANCE!!!
mirn, look at this site: http://www.insure.com/health
THIS IS AN EXCELLENT SITE FOR PEOPLE WHO DON'T UNDERSTAND HEALTH INSURANCE/HMO'S OR HOW THEY WORK.
ALSO, TRY THIS ONE EVEN THOUGH IT'S A LITTLE EXTREME: http://www.hmopage.org
I THINK THAT AS NURSES WE SHOULD ALL ARM OURSELVES WITH AS MUCH KNOWLEDGE OF HMO'S/INSURANCE AS WE CAN!!!