Choosing Your Managed Care Doctors
Source: AARP.org | 2006-11-07 15:55:00-05:00
One of the first things many managed care plans, especially health maintenance organizations (HMOs), ask you to do is choose a primary care doctor. Your primary care doctor is the doctor you see for routine check-ups and when you are ill. This is your most important partner in your health care. He or she coordinates your health care and sends you to a specialist or hospital if you need it.
For these reasons, it is important to trust your doctor and feel comfortable talking with him or her about any health issues that concern you.
Your primary care doctor is usually a "generalist." A generalist can be a general practitioner, an internist, or a family practice doctor. These doctors focus on the whole body.
If you want to have a specialist as your primary care doctor, ask your plan. For example, some women prefer a gynecologist as their primary doctor. Be sure to talk to your specialist about this. Some specialists do not want to coordinate your health care needs. They may not be comfortable working on medical problems outside their area of expertise.
Choosing a Primary Care Doctor
- Ask if you can interview the doctor, either by telephone or in person. This gives you a sense of his or her style and whether you feel comfortable with that person. Talk about what you want from a doctor and what the doctor will expect from you. You might have to pay for this interview with your own money, but it could be worth it.
- Talk to other health plan members about what they like and don ' t like about different doctors.
- Check the plan directory to see if it contains information about doctors ' education, training and special interests. Find out if the doctors you are considering are " board certified " in their field. " Board certified " means that they have taken extra training and passed tests in certain areas of medicine. You can also find out if your doctor is board certified from the American Board of Medical Specialties.
- Contact your state health department or medical board for information on complaints or actions taken against doctors. You can also search the web sites of several groups that collect information on disciplines taken against doctors.
- Ask whether the doctor is taking new patients. Some doctors limit the number of new patients they will see.
- Ask how long you must wait for an appointment. Some doctors have waits of four to six weeks. The length of your wait might depend on the kind of problem you have.
- Find out how easy it is to reach the doctor during the evening and on weekends in an emergency, or if your plan has a special advice line when the office is closed.
- Check out the doctor ' s office location, hours, parking availability, whether you can get there by public transportation, and if it has access for people with disabilities.
Staying With Your Current Doctor
Perhaps you have been going to the same doctor for many years. If you joined a new health plan and want to stay with your current doctor:
- Check your plan ' s list of participating doctors to see if your doctor is listed. Call your plan ' s member services department if you need help or ask your doctor.
- Ask if your doctor is seeing patients from your new managed care plan. Sometimes doctors will take only so many patients from managed care plans. Even though you have been going to your doctor for many years under one health plan, there is no guarantee that the same doctor will see you when you change plans or that he or she will practice the same way you are used to.
If you can stay with your current doctor, ask what will change when you see your doctor as part of your new plan. For example,
- Your doctor might have to send you to different specialists or hospitals that are part of the managed care plan ' s network.
- The amount of time your doctor spends with you may change. Many managed care plans want doctors to see a certain number of patients every hour.
- The plan prescription drug benefit might determine what medicines your doctor uses. Your doctor may need to switch your prescription drugs to those approved by the plan.
- Your doctor might have to use the plan ' s laboratory to process your tests.
Changing Your Primary Care Doctor
It takes time to build a good relationship with your doctor, so that he or she knows all about your health and medical history. There may be a time, however, when you need to change your primary care doctor because:
- You are unhappy with the care you are getting.
- Your doctor is no longer part of your plan.
- Your plan drops the doctor from its network.
Most managed care plans let you change your primary care doctor. Be sure to follow plan rules regarding the change. Remember to ask your former doctor to send copies of your medical records to your new doctor. You may be charged a fee for copying your records.
Getting a Referral to a Specialist
Many people see their primary care doctor for most of their health care needs. But sometimes it's necessary to see a specialist. Here's how you can see a specialist when you are in a managed care plan:
- Referrals Inside Your Managed Care Plan
In many managed care plans, especially HMOs, your primary care doctor must give you a written referral before you can see a specialist in your plan's network. The referral tells you how many times you can see the specialist. - Referrals Outside Your Managed Care Plan
Learn your plan's rules for seeing specialists who are not part of your plan. Find out how much you will pay for the visit and how much your plan will pay. Know if your plan will pay your hospital bills if you are admitted to the hospital by an out-of-network specialist. You don't want to be faced with large hospital bills if you don't follow the plan's rules.
Additional Resources
U.S. Agency for Health Care Research and Quality (AHRQ)
Gives tips on choosing a doctor in "Your Guide to Choosing Quality Health Care" and "Choosing and Using a Health Plan."
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