What to think about when choosing your policy during Open Enrollment: HMO vs PPO

–from a medical office manager’s point of view

Open enrollment is the time when you need to use your best guess to how much you and your family will be going to the doctor in the upcoming year. This is a tuff guess but think realistically based on the past year.

With so much changing from year to year, I have been getting a lot questions from patients wondering what to do.

First, is there an HR person who handles your insurance benefit choices? They should be able to assist you in picking the best one for your needs. Know what your needs are.

Do you see a lot of specialists? Do you have specific doctors you want to continue seeing? Do you rarely go to the doctor unless an emergency? All this factors into what plan is best for you.

I usually tell people if they see a lot of specialists then PPO is the way to go. Generally speaking it is harder and time consuming to get pre-approvals from primary doctors. This causes most specialist visits to be an out of pocket expense for patients. However, HMO policies have less expensive premiums. For someone people they choose HMO and just pay out pocket anyway for their specialist visits if not covered. Sometimes it is more financially beneficial if the premium per month for HMO vs PPO are a tremendous difference. If it’s not a big difference PPO is always the better choice if you use specialists and want to choose your own doctors.

For our office, we are a considered a specialist in the insurance world. This means for any HMO policy we MUST HAVE a referral from your primary care physician before we are allowed to see you IF you want it to be covered by your policy. Treatment cannot be retro activated. This means you cannot make an appointment with our clinic, come in and receive treatment, and then go ask your primary to get the referral.

Our clinic is not a part of every HMO policy. Just because we accept BCBS does not mean we are contracted with your HMO plan through BCBS. The only way for us to really know is to call BCBS once we have your member ID# and group#. Some HMO plans don’t have chiropractic coverage. Some do not have a chiropractor in their plan to choose from. Some only have one chiropractor they are allowed to refer to. Other plans are have primary doctors that do refer to local chiropractors for treatment.

Curious to see if your HMO plan refers for chiropractic? Here’s what you do:

  • Your HR person may know. They may have a list of doctors.
  • Call the doctor’s office and specifically ask if they allow chiropractic treatment
  • The phone # is on your insurance card.
  • Ask if they refer to a chiropractor of your choice or do you need to use one in their network
  • Ask for a list of chiropractors in their network. EVERY HMO doctor’s office has a master list of who is involved within their network. At the very least they should be able to direct you to a website that lists all doctors in the network.

So is an HMO bad? NO, it depends on what your needs are. What is right for you might not be best for someone else. That’s why there is a choice.

Picking which insurance is right for you is tuff. Especially now when so much about insurance has been changing from year to year. Choosing really comes down to each person individually and what they need. Don’t look at just the premium price. Know your needs.

Hope that helps! Insurance is tricky I know. 🙂 One thing is for sure, it is ever changing. The best way to stay ahead is to educate yourself on your policy and what options you have. And use your resources. Talk to your HR person, talk to fellow employees that have the same insurance. Don’t be afraid to talk doctor’s offices. Their staff handles insurance on a daily basis. They, like me, have a wealth of knowledge from years of experience dealing with insurance claims from the backend, AND they are on your side. They want your claims paid just as much as you do.

Happy open enrollment! Till next year.

–Alicia Williams
Office Manager@ Hart Chiropractic