Paducah, KY
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Mellow Greetings
I work for a DME (orthotics) company and we are starting to see more HMO/IPA plans (AZ, TX, IN & KY). As I train my department for these types of payers, I'm looking for a better way to explain how to differentiate when the HMO plan requires a PCP referral versus when it doesn't without having to call the payer each time. When the benefits department checks eligibility on the portal, they've been instructed to review all aspects of the verification to ensure they're not missing anything indicating a PCP referral is required or if it's an IPA. The insurance card is another way they've been taught to check, but it's not always present in the chart. Not all HMO plans require a PCP referral for an ancillary service and it seems to be a confusing subject! I'm trying to minimize their phone time by learning how to navigate these HMO plans and wasting time requesting a referral when it's not needed. The service is all inclusive, from the evaluation to the delivery, so there's no separate charge for an office visit(s).
I've explained when they come across an IPA plan, we need confirmation on who's at risk.
I've found others sometimes have a better way of explaining things that makes more sense, so I'm all ears!! Thanks in advance! :)