Due to the nature or severity of injury or illness, referrals to a specialist or diagnostic testing may be required and will be scheduled by Tri-City staff as ordered by your Tri-City physician. Please read below section entitled “Managed Care” for more details on “referrals”.
The primary care physician’s role in an HMO insurance plan is to provide quality, cost effective care in the physician’s office, and to coordinate health care services when indicated, outside the primary care physician’s office. Referrals are given on the basis of medical necessity as evaluated by the doctor. As such, referrals are not made without an evaluation/exam by your primary care physician.
Going to a specialist without a referral will result inthe specialist’ claim being denied, and you will be responsible for the bill. We cannot backdate or give a retroactive referral.
Emergency room visits are also costly to the health plan, and when deemed not medically necessary by the health plan, are billed to the patient. Don’t wait until the evening or weekend to seek care. If you do become ill late at night or on the weekend, and fell you cannot wait until the office re-opens, call the answering service and the Tri-City physician on-call will contact you to advise you.
The primary care physician has no say in whether your insurance company will pay for an emergency room visit. Any questions regarding payment should be directed to the member services department of your insurance plan or the benefits administrator at your place of employment.
Read your health insurance policy or the brochure outlining the terms of your coverage so that you understand your benefits and responsibilities for deductibles and copays.
Working together, we can achieve quality, cost-effective health care for you and your family.