Why Do I Need My Doctor’s Approval To See A Specialist? (Responding To Readers)

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“Why do I need my doctor’s approval to see a specialist?” This is a question that a number of members in HMO plans often ask. In PPO plans, members don’t need referrals to see specialists. Still, with HMO plans, there are more rules and a dominating qualification of “medical necessity” for every visit the member makes to a specialist. And so, a member who calls his or her insurance company about authorization to see a kidney doctor or nephrologist may ask, “Why do I need to see the doctor and get his or her approval before seeing a specialist?”

Well, this topic is too important to gloss over and fly through. So, to give this question the treatment it deserves, we’ll have to take our time and thoroughly assess the situation.

What do you mean by “my Doctor”? Explaining what pcp stands for

PCP is an acronym, a shorthand letter form used to represent a familiar concept. If someone says “MLK,” you don’t have to know the “L” stands for “Luther” to know that the man in question was a preacher and famous civil rights leader. MLK stands for “Martin Luther King,” by the way. If someone says “USA,” you immediately recognize it’s an acronym for “United States of America.” Think of states in the US, such as “FL” for “Florida” or “TX” for “Texas.” Acronyms are a way to abbreviate a familiar concept, term, or item. We use the term “Dr” for doctor, someone who practices medicine. “RN” stands for “Registered Nurse.” “CNA” stands for “Certified Nursing Assistant,” and so on. When it comes to “Doctor,” we are also familiar with the term “MD” behind names; it stands for “medical doctor.”

There is an acronym that is all too common when talking with your insurance company: it is the term “PCP,” which stands for “Primary Care Physician.” You must remember this term and repeat this term until you memorize it, because it is the one term you will hear most often when calling your insurance company. When the insurance agent refers to “your doctor,” they are talking about the PCP or Primary Care Physician.

why is the doctor called the pcp?

Why is your doctor, the one you meet with regularly, called the “PCP”? Well, to answer this question, we must also address why it is that the first “P” in PCP stands for “Primary.” Why is this doctor the “Primary” Doctor? The PCP is the Primary doctor because he or she is the first (or primary) medical advocate that you have. You may see a specialist every few months, for instance, but on HMO plans, you can see your “Primary” Care Physician as much as you wish. You can see the PCP every month if you desire to. This doctor is “primary” in your list of medical advocates.

Since the PCP is the “primary” care physician, this doctor is the one that your HMO insurance company does business with when it comes to your health: the HMO plan pays this “primary” care physician to meet with you, take down medical notes of their patients for every visit, and so on. When the insurance company takes your requests for authorization to see a specialist of any kind, guess where it will turn? To the “Primary” Care Physician.

The PCP is called “primary” or first, for a reason. Your HMO plan has not assigned you a PCP when you enter the plan without reason. It has assigned you a PCP from the first day of your effective date because that PCP is the primary source of your medical information. Additionally, the PCP can determine the specialists that you see. So, you cannot go and see a specialist in many cases unless your PCP gives his or her consent.

Now, there are certain self-referred fields where you do not need authorization to see a specialist: dermatology, optometry (routine vision exam and glass-fitting, for example), gynecology, dentistry (routine dental checkups each year, for example), and chiropractor. All members in HMO plans have benefits in these areas and can go visit these specialists initially without authorization of any kind. Now, these doctors may find something suspicious or wrong and want to explore it further, at which point, the PCP or Primary Care Physician may have to get involved (to file authorization and get the plan to pay for more visits). But initially, members should be fine to see these doctors without paperwork of any kind.

A routine eye exam at the optometrist may turn up something in a member’s eyes that merits a referral and appointment to the ophthalmologist, but the member can see the optometrist without paperwork (due to routine eye exam and visit). The optometrist, seeing something in the member’s eyes, may give a referral to the ophthalmologist (eye specialist).

However, when it comes to most medical fields, members must get approval in HMO plans from their Primary Care Physician before seeing the specialist. And why must members have to get approval from the PCP to see the specialist? First, because the PCP is the “Primary” Care Physician. “Primary” means first; you cannot have a PCP that you only seek approval from after the fact. Why would he or she be called the “Primary” Care Physician if you seek their medical approval for the specialist “after” you’ve been to the specialist and not before?

PCP chooses the specialists you can see

Another reason why the “Primary” Care Physician has to give consent to members in HMO plans is that they can also choose the specialists members can see. Let’s say that you choose one PCP when you join the plan but then, once you join, you discover that your former PCP (before you enrolled) is approved by the plan. You call your local insurance company to switch your PCP and go back to the one you’ve been seeing for years. And then, you remember that you’ve received an auth for a visit to the pain management specialist from the former PCP. Well, if you change your PCP, then the referral you received to the specialist is now null and void because the PCP you had is now “former” and not present.

The PCP chooses the specialists you can see in HMO plans. In fact, the PCP is the one that visits with you regularly and says, “based on what I observe, you have a medical issue that I cannot treat in my knowledge and experience. I’ll have to refer you out to a particular specialist.” The problem with some members in HMO plans is that they would rather select a specialist that’s close to where they live. This specialist may work for your transportation trouble but he or she may not have the medical expertise your PCP finds sufficient. But when it comes to medical decisions and medical opinion, why should you make the decision instead of your PCP? Why trust your PCP for every other medical decision EXCEPT when it comes to specialists?

If the PCP has no medical authority to recommend specialists for you and on your behalf, then why trust him or her at all?

life without the pcp: why primary care physicians are so central to your health

Many members ask the question, “Why do I need to see the PCP for approval to see the specialist?” Well, we are about to take a trip down the hypothetical lane and imagine the downside to life without the PCP.

Let’s say you have a rash that develops. You don’t know what it is, so you say, “Let me go to the dermatologist.” Then you go to the dermatologist and the dermatologist sees some spots develop that he says are examples of kidney failure. “You need to see the nephrologist,” he says. Then you go see the kidney doctor and the kidney doctor says, “I don’t know what’s on your foot but you need to go back to the dermatologist for more info.” So you go back to the dermatologist and he or she then sends you to the podiatrist. The podiatrist asks you questions and says, “since your foot issue is tied to your back pain, you’re gonna have to go to pain management.”

Let’s say that you have need of home healthcare and so, the plan says, “we need medical notes from all of your doctors.” Imagine all the effort you’d have to put forward to receive all those medical notes. You would have to call all your doctors (if you are fortunate enough to retain their contact info) and requests all your medical records, tell them “send those medical notes to my insurance company). If you don’t remember all the doctors’ names or have some way to get ahold of them, you’d be out of luck. Having to call all those specialists for medical notes when it comes to getting authorization approved would be a tiring exercise, wouldn’t it?

That’s where the PCP comes in: his or her job is to act as the “Primary” or central Care Physician so that, when the plan needs medical notes to make a determination, the PCP can send all the medical notes without delay. The plan doesn’t have to call different specialists to obtain notes on you; they can just contact the PCP. When you need your medical notes, you need only call the PCP’s office and request them; you don’t have to wait for every specialist to send their medical notes, or contact so many doctors’ offices to request your medical notes. Additionally, the PCP can obtain all the medical information available for you so the doctor can keep an eye on existing conditions and refer you out should you have a sudden and immediate need.

With a Primary Care Physician who keeps track of all your medical documentation and has the power to refer you to specialists, your medical care access is better than ever. That Primary Care Physician is the centralized source of medical information as well as medical authority for members in HMO plans. It’s much easier to get you the healthcare you need when one doctor has all the information, as opposed to so many doctors having only fragments of information.

specialists and the pcp: how it all works together (conclusion)

With the PCP or Primary Care Physician playing a “primary” and central role in your medical care, he or she gives organization to your healthcare and medical experience. The PCP chooses the specialists that members can see and stays in touch with those specialists to coordinate your care. The PCP acts as the source of central health information when the plan prepares to authorize visits to specialists for members. The PCP should stay in touch with specialists so that he or she is aware of what’s going on with his or her patients. And, since the PCP selects these specialists for the members (unfortunately, too many members attempt to make specialist selections themselves), he or she knows how to stay in touch with said specialists. Some members join the plan and have been seeing certain specialists for years.

If those specialists are on the same HMO plan and in-network, few doctors dissent to patients seeing specialists they already have a close relationship with. Doctor-patient relationships are all about trust, and building trust with your medical officials is hard to come by in any setting. So with that said, PCPs are open to members having preferences for specialists, but sometimes, the PCP’s desire to give you the best healthcare possible clashes with a member’s desire to have a particular specialist.

PCPs and specialists work a lot like the body does. Paul talks in 1 Corinthians 12:20 about how there are “many members, but one body.” While all the parts of the body work in their own respective designs, ultimately, they are all part of the whole body and have to function as one. When one body part stops functioning properly, it affects other parts of the body as well. And so, no one asks why we need the body to function as one; we know the answer. No one says that “I don’t need to worry about the whole body because my knees are fine,” or “I don’t need to worry about my back because my kidneys are fine,” for example. We know that as good as any one body part is, it cannot function on its own; it must work as part of the coherent whole in order that we may be healthy and well.

Why is it, then, when it comes to PCPs and specialists, so many members are willing to throw off the PCP for the specialist? Why is it that we cannot understand that, in order for our medical care to be great, we must see the central role the PCP plays in it and allow the PCP to coordinate care with our specialists? It seems clear to me: “many members, but one body,” and “many specialists, but one PCP.”

What say you?