Jul 30, 2008

Preapproval of Visits to Specialists

Many persons elect to bypass primary care physicians, such as family physicians and pediatricians, and use specialists and the emergency room as their primary access to medical care; this results in additional costs but does not improve medical outcomes, in the opinion of much of the medical community. To counter this practice, some traditional medical expense plans require that a visit to a specialist be preceded by a visit to a primary care physician. It is not necessary for the primary care physician to actually certify that a trip to a specialist is necessary, only that he or she has been told that the patient plans to make such a visit. The rationale for this procedure is that the primary care physician may convince the patient that he or she is able to treat the condition and that a specialist is unnecessary, at least at that time. If a specialist is needed, the primary care physician is also in a better position to recommend the right type of specialist and to coordinate health care for persons seeing multiple specialists.

Failure to use the primary care physician as a quasi gatekeeper will result in a reduction in benefits. Usually, benefits will still be paid, but at a lower level.

Benefits for Preventive Care
Most traditional medical expense plans provide at least a few benefits for preventive care. Probably the most frequently found benefits, because of state mandates for group insurance contracts, are well-baby care, childhood immunizations, and mammograms. Plans may also go as far as providing routine physicals for children at specified ages and, perhaps, for all covered persons, typically subject to an annual maximum benefit, such as $150 or $200. However, coverage for routine adult physicals is much more likely to be covered under managed care plans.


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