FAQ: How Do Referrals Work in a POS Plan?

POS plans are a type of managed care health plan that grants policyholders the ability to see both in and out of network practitioners. Within a managed care health insurance system there is a system of doctors, hospitals and health practitioners under contractual obligation through the insurance provider. When an individual chooses to sign up for managed care, the first thing they will need to do is choose a primary care physician (PCP). With a POS plan, the member can see both doctors within the service network and outside of the policy. If the member has a condition for which they want to go outside of the service network for treatment, they still must get a referral from their PCP.

Primary Care Physicians

PCPs act as the gatekeepers for POS plans. To help manage the overall cost to the insurance companies, the PCPs are really the first line of defense to ensure that any additional treatment by a specialist is actually necessary. The member must first see the PCP, discuss their condition, and the PCP will then work closely with them to decide the most beneficial path for treatment including making the necessary referrals for the POS plan to contribute to the expenses.

Many POS plans also pay coinsurance for those appointments that are considered a “self-referral.” Self-referral is when the patient opts to visit a doctor outside of the service network system without getting authorization from their PCP. When this occurs, typically the rate of coinsurance contribution the medical insurance will kick in is a lower percentage than if someone follows the proper POS referral steps.