FAQ: How Do Referrals Work in an HMO?

Health maintenance organizations are a type of managed care health insurance provider. By joining an HMO, a member can benefit from quality medical attention focusing on preventative care at an affordable rate. When you opt to join an HMO, one of the first decisions you need to make is selecting a primary care physician. This physician will be your main point of contact and if you need any type of specialized care, you will need to see them first to get a referral.

Getting a Referral

As the gatekeeper of the HMO network, the primary care physician is responsible for overseeing the well-being of their patients as a whole, and are in charge referrals. Without a referral from a primary care physician, you will have to pay all expenses out of pocket if you decide to visit a specialist on your own, even if they are in your network.

Specialist Access

HMOs tend to have a full range of specialist who are all contracted by the insurance provider. By seeking the referral from your primary care physician within an HMO, you should be able to get access to and assortment of healthprofessionals, doctors, hospitals, mental health care workers, and other specialists. As the gatekeeper to the HMO service network, primary care physicians will give you the necessary referral if you need a specialist.

Although some people prefer flexibility in their health care plans, many like the one-stop-shopping that an HMO can provide them. An HMO that is properly set up can be a great service network for those who are new in town and are looking for all their doctors in one convenient location. Additionally, within the HMO referral system, communication is better between doctors handling your case due to advances in information sharing between in-network physicians.