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December 26
Guide to Finding a Medical Specialist Covered Under Your Health Insurance Plan

Guide to Finding a Medical Specialist Covered Under Your Health Insurance Plan

Finding a medical specialist you can entrust with your health can be a daunting prospect. Often a lot is riding on your decision and the stakes can be high. That is why many people are frustrated by what they perceive as the added complication of having to find a specialist who is covered by their health insurance plan. However, the goal of the health insurance company isn’t to make the process of finding a specialist more difficult, but rather to ensure that the specialist you ultimately do see will be highly qualified and able to dispense the care you need. What follows is a guide to finding a medical specialist covered under your health insurance plan.

Medical Specialists and Why They Are Needed

A medical specialist is a doctor who specializes in a specific area of medicine. For example a cardiologist specialize in heart health; an oncologist specializes in treating cancer; a podiatrist specializes in foot care, etc. Specialists are an invaluable medical resource because their greater degree of focus allows them to gain valuable experience and expertise in their chosen fields. It also allows them to stay extremely well-informed and current about all medications and treatments within their area of practice. A primary care physician by contrast treats a much wider array of diseases and ailments and must balance his or her time and attention among many different areas.

Finding a Medical Specialist Based on Plan Type

Many people are uncertain what type of health care plan they have and even once they find out, they may still be confused about what the differences are between the plans types. It is very important to understand your health care plan so that you can maximize your coverage and get the most benefit and best care without incurring extra costs. It is particularly important to understand your health care plan when you are looking for a medical specialist because the various plan types treat care given by a specialist quite differently. If you are uncertain what type of health care plan you have, you can usually find the information simply by looking at your health insurance card. Alternatively you should be able to call your health insurance company to find out. There are three main types of managed care health insurance plans. They are as follows:

Health Maintenance Organizations (HMOs) – HMOs are a fully integrated managed care plan whereby the doctors, hospitals, and insurers within the plan all work together to provide care for patients on a prepaid basis. This prepaid status means that patients do not pay more depending on use. If a patient goes to a doctor or hospital one month they will pay the same amount that they would have on months when they did not seek any treatment. This provides a strong incentive for patients to get preventative care and to seek medical attention as soon as they need it.

However, because HMOs feature a tight cohesion between the insurers, doctors, and hospitals, patients must get a referral from their primary care physician before they can seek treatment from a specialist. Without a referral treatment by a medical specialist is generally not covered at all by an HMO.

Preferred Provider Organizations (PPOs) – PPOs have more flexibility than HMOs in that patients are still covered if they get treatment outside of the provider network. However, patients get a larger discount if they use providers within the network. Unlike HMOs, PPOs are not prepaid. Instead the patient will pay after the service or doctor’s visit and will thus naturally pay more for higher/more frequent use.

With PPOs a patient is not required to get a referral from their primary care physical before seeking out a medical specialist. However, there is usually a financial incentive to do so because PPOs generally give more of a discount if the patient first got a referral.

Point of Service (POS) – POS plans combine many of the qualities of HMOs and PPOs. As with HMOs there is often no co-pay or deductible for seeing physicians within the network. If patients go outside of the network, they will usually still enjoy some coverage and often capped out-of-pocket expenses. With POS plans in order to enjoy the full in-network coverage patients usually do need to first obtain a referral to a medical specialist from their primary care physicians.

Resources for Finding a Covered Specialist

As the above information illustrates, using a covered medical specialist is generally the best route to take to obtain the most coverage and benefit from your health insurance plan. Finding a covered medical specialist can be done using one of the following resources:

Primary Care Physicians – A primary care physician, or your “family doctor,” will typically be the best way to find a medical specialist covered under your plan. Your primary care physician will be able to assess your need and may even be able to make specific recommendations based on your individual concerns and preferences. Additionally, as mentioned above a referral from your primary care physician will generally save you the most money.

Insurance Website – The website for your insurance company will often include a tool to help you find a covered medical specialist in your area. Often you will be able to enter your zip code to find the one nearest in proximately, or you can search by city or state. Naturally insurance websites will vary, but most have some type of resource for find specialists.

Insurance Customer Support – Your health insurance card will almost certainly have a 1-800 number, or other customer support number, on it that you can call to speak to a representative. The customer service agents for your insurance company will generally be able to give you the information for a covered specialist in your area either over the phone, or they can mail or email you the information. They may also be able to walk you through the process of finding the information on the insurance website.

Medical Specialists – If you already have a medical specialist in mind that you would like to use, you can call her or his office and inquire whether or not he or she is covered under your insurance plan. If the answer is no, you can often receive a recommendation for additional specialists simply by asking.

Other Resources – Friends and family may also be able to recommend a medical specialist. Often this is more effective than it might seem for finding a specialist covered under your plan, because frequently family members are covered under the same health insurance plans, as are friends who also happen to be co-workers covered by the same group health plan. Once you receive the name of the specialist you can also call them yourself to inquire about coverage, or call your insurance company to check, as mentioned above.

Finding a covered medical specialist does not need to be an ordeal or something that you dread. Though there may be extra steps involved more often than not your doctors and insurance provider will probably want to work together to get you the best care and coverage possible. Together your health insurance company and current physicians make up the best resource available for finding a covered specialist; never overlook the option of simply asking them for help.