HMO Insurance : Do I Always Need To See a Primary Physician?

Health Maintenance Organizations are based upon the idea that pools of patients substantially reduce costs of healthcare for providers and the insured. The basic premise of HMOs is that by utilizing primary care physicians as “gatekeepers”, costs are significantly reduced for specialists, diagnosticians and emergency room care.


Whether or not it’s necessary to see a primary physician is dependent upon the type of HMO plan policies and specific HMO provider. For some HMOs, engaging a primary physician is mandatory. With a primary physician acting as a gatekeeper, a patient may subsequently be directed to a specialist if the primary physician is incapable of managing the diagnosed illness. For example, not all primary physicians have experience in cardiology, oncology or auto-immune diseases. A referral is usually required by the HMO from a primary physician who will choose the specialist from the HMO’s approved network of doctors.


As the HMO gatekeeper, it’s usually the responsibility of the primary physician to make necessary referrals for hospitals for surgery, etc. In addition, the primary physician may also be responsible for referrals to diagnostic laboratories in order for HMO insurance claims to be accepted for payment. HMO insurance primary physicians provide referrals for blood testing, X-rays, MRIs, CAT scans, EKGs and EEGs. The primary physician is also responsible for monitoring medications prescribed by specialists. Thus, a primary physician must receive reports from all specialists from whom treatment is received. HMO insurance providers generally furnish their insured with a comprehensive catalog of prescription drugs the HMO will approve for claim payment. HMO insurance coverage may also include preventive care such as mammograms, colonoscopies or PAP testing. Certain HMO also provide for insurance coverage for optical and dental care. In some cases, primary physicians make referrals for these types of coverage. If this isn’t applicable, patients may be reimbursed for costs for these services.

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