Patient choice referrals – what they are and why they matter

Choosing the healthcare providers who care for you, or your loved ones is a valuable part of successful health care. It’s important to work with a facility that makes you feel comfortable and confident in the care you receive. While some insurance programs may limit which facilities or providers are available to you, it’s still up to you to choose the primary care physicians, specialists, hospitals, and nursing homes you want to care for you.

Understanding your coverage

The first step in understanding your health insurance coverage is to know what type of coverage you have.

  • Traditional coverage typically allows you to see any doctor that accepts your coverage and may reimburse you once you’ve met deductibles.
  • An HMO (or health maintenance organization) allows you to select a primary care physician from among their affiliated doctors, who then coordinate your care among specialists and other services.
  • A preferred provider organization (or PPO) is similar to an HMO, but you do not need to select a primary care physician and you do not need referrals to see other providers in the network. Because of this flexibility, PPO plans tend to be more expensive than HMO plans with otherwise comparable benefits.

Being proactive on referrals  

Depending on the type of health insurance you have, your plan may require a referral from your primary care physician (PCP) to see a specialist or take advantage of additional services such as physical therapy. While your PCP will likely refer you to a specialist that is part of his or her practice or someone they’ve worked with in the past, you can ask your PCP to provide a referral to the specialist of your choice, provided they are part of your network.

Some health plans require the referral to be in writing directly from the doctor, while others will accept a phone call from your primary care physician.

Make sure everything is in order before you schedule an appointment to see a specialist. Call to confirm that your insurer has received a referral before you make an appointment with your specialist and be sure to ask about any special copay under your healthcare plan.

Getting prior authorization

Depending on your coverage, you may need prior authorization from your insurance plan along with a physician referral. Your physician may automatically obtain prior authorization as part of the referral process, but you’ll want to double-check with your insurer and the specialist before you receive treatment.

Making your own choices  

Regardless of your insurance coverage, the choice of healthcare providers is always up to you. For example, as you or a loved one prepares to leave the hospital or transition from home to a nursing home, your family physician or hospital care team may provide you with a list of suggested facilities from which to choose. It may be tempting to limit your choices to that list — after all, the many options available to you may be overwhelming — but it’s important for you to know that you have the option to select any nursing home provider you prefer, even if it’s not on the list of suggestions.

To help evaluate and select the nursing home facility best suited for your needs, Medicare has developed a website specifically to help you compare nursing home options based on several ranked factors. You can easily find those that are close by, accept Medicare, Medicaid, or your private insurance, determine which are part of a continuing care retirement community, and perhaps most important, the facility’s overall rating. The Medicare rating system evaluates nursing home facilities based on health inspections, staffing coverage and ratios, and 15 physical and clinical quality measures, giving you a straightforward way to compare options side by side.

The American Health Corporation operates four nursing centers in Alabama, all of which are 4- or 5-star CMS ranked skilled nursing facilities: Colonial Haven Care and Rehabilitation Center in Greensboro, AL,  Perry County Nursing Home in Marion, AL, and Oak Trace and Terrace Oak Care and Rehabilitation Centers in Bessemer, AL.

Finding a guide to help navigate your options

Helping an elderly family member or loved one select a trusted partner in maintaining their health is key to their overall success. Because each choice can have very different financial impacts, it’s helpful to have a guide through the complexities of insurance. The team at American Health Corporation can help. Their team is well prepared to help navigate the potential issues surrounding selecting various providers, and they can help you select the highest quality healthcare providers, facilities, and programs to help patients maintain skills and abilities to live as independently as possible.

For more information or to schedule a facility tour, contact one of our locations in Alabama nearest you:

Oak Trace (Bessemer, AL) 205-428-9383

Colonial Haven (Greensboro, AL) 334-624-3054

Perry County Nursing Home (Marion, AL) 334-683-9696