Open Enrollment - Page 13 - Navigating Specialists in Your Health Care Coverage

Open Enrollment
- Page 13
Navigating Specialists in Your Health Care Coverage
Ask key questions to avoid unnecessary costs

By Emily Parks
Contributing Writer

Many are familiar with the role of health insurance coverage, with participants paying a co-pay per visit for annual checkups such as mammograms or visits to the primary care physician for illnesses. But what happens when your primary care physician wants you to be seen by a specialist? How do you know which specialist to call? How do you know if that specialist is in your network? And most importantly, what services provided by the specialist are covered by your insurance?

All of those questions are important to ask when navigating your health care coverage. Mary Crawford Perry, director of patient access and revenue cycle and Chris Knott, revenue cycle liaison, both at University of Maryland St. Joseph’s Medical Center in Towson, advise patients to be their own best advocate when it comes to determining coverage for your health care needs. They both agree a good place to start is by checking the website of the health insurance provider. “You can check to see if the physician you’d like to see is in your network, what your benefits are, how much you’ve paid toward your deductible as well as the status for claims,” Knott says. “It’s a great place to start.”

Shital Desai, M.D., physician in chief of the District of Columbia and suburban Maryland service area, Mid-Atlantic Permanente Medical Group agrees. “Specifically to Kaiser Permanente, we have a pretty robust website, onboarding and welcome package for new patients that will give you an idea of what services are covered as well as the depth and breadth of our services,” she adds.

Both Perry and Knott encourage patients to make sure they have all the information they need on their behalf when it comes to next steps in their care, whether it’s if you need a referral from your health insurance provider before you even see the specialist, or if the specialist you’d like to see is in your network of care providers. “Always verify (with your health insurance provider) if you need a referral or not,” Perry says. “Be your own advocate, know your own insurance and as we like to say to our patients, ‘Know before you go.’”

Even though the onus is on the patient to understand coverage and policies surrounding their care, the primary care physician is still a partner when helping a patient choose a specialist. “I think my primary care physician would send me to someone who he would refer his own family members, but at the same time you want to make sure the recommended specialist participates in your insurance,” Perry says. “Some doctors are usually pretty good about providing a list to their patients from which to choose a specialist.”

In some instances, the primary care physician can play a larger role in connecting the patient with a specialist, often with good outcomes regarding patient care and satisfaction. Primary carephysicians with Kaiser Permanente coordinate and schedule appointments with specialists on behalf of their patients, allowing for a seamless transition between primary care and specialty care. Primary care physicians with Kaiser Permanente utilize eConsult, which allows them to directly book the appointment with the specialist in real time. Desai notes that as a result, it improves adherence to visits, not to mention the patient experience, as they are not having to coordinate their own care and spend their own time booking appointments.

In addition, it ensures the patient gets the right care in the right venue, as the primary care physician has the “bird’s eye view” of the patient’s care and treatment needs. “Within the Mid-Atlantic Kaiser Permanente Medical Group, we are all very well-connected to each other, so I can make sure that before a patient sees the specialist that all the pre-work is done in terms of imaging and lab work so when they do see the specialist they are getting the most out of that visit,” she explains. “It improves the care that we’re providing, it improves the patient satisfaction and is often a time and cost saver for the patient as well.”

In addition, Desai can utilize secure messaging and special services such as teledermatology to coordinate primary and specialty care. With teledermatology, the primary care physician can take a photograph of the skin lesion with a high-resolution camera, upload the photograph to the system and have the dermatologist reading those images in real time with a response in usually 20 minutes. “The dermatologist can come back with a diagnosis and treatment plan, all occurring while the patient is still sitting in the primary care physician’s office,” she says. “You’re saving the patient time for another appointment as well as saving them another co-pay associated with attending another visit.” The primary care physician with Kaiser Permanente can also schedule services such as MRIs and CT scans.

For an MRI or a CT scan, a preauthorization, or a prior authorization, is often a necessary step. According to the webpage for Blue Cross Blue Shield of Illinois, certain health care services and prescription drugs may need to be approved before they are covered. The site advises contacting customer service to determine if a health care service needs pre-approval. Whether your doctor is in-network or not determines who will needs to submit a request for prior authorization, as the site notes if the doctor is in-network, the doctor will need to submit a request for prior authorization; however, if your doctor is not in your plan’s network, the patient will need to contact the health insurance provider to obtain prior authorization.

Arming yourself with knowledge is key while navigating health insurance coverage in an effort to be your own best advocate. Perry recommends becoming familiar with health insurance terminology and your policy as best you can. “I think it’s important for patient to know what a deductible is, know what co-insurance is, what is a co-pay and what your out of pocket costs could be for a surgery,” she says. “Again, always know before you go.” •