Minnesota Attorney General's Office
1400 Bremer Tower
445 Minnesota Street
St. Paul, MN 55101
M - F 8 am - 5 pm
Common Questions and Answers About Managed Care
To help you understand your rights as a patient in managed care, we've provided answers to some of the most commonly asked questions.
MY HMO WANTS TO CUT MY HOSPITAL STAY SHORT. WHAT CAN I DO?
Enlist your physician to be your advocate. Talk frankly with your doctor. Express your concerns and ask the doctor to intervene with the health plan. Ask the doctor to explain to the health plan the negative health consequences you could suffer if you leave the hospital. You should also express your concerns directly to your health plan, preferably in writing.
MY PRIMARY CARE PHYSICIAN WILL NOT GIVE ME THE REFERRAL THAT I NEED TO SEE A SPECIALIST. I AM VERY CONCERNED ABOUT THIS. WHAT CAN I DO TO GET A REFERRAL?
Some health plans use primary care physicians as "gatekeepers" to control the treatment and referrals you receive. In addition, some health plans pay the gatekeeper a "capitated" payment.
This means that the gatekeeper receives a flat fee regardless of the amount of treatment you need. In other words, the more referrals the patient needs, the less money the gatekeeper makes.
Tell your physician about your concerns. Tell your physician why you believe it is necessary for you to receive a referral to a specialist. Again, consider putting your concerns in writing. If this doesn't work, you may also wish to consider changing primary care physicians.
Finally, if you still can't get a referral to a specialist, consider locating a specialist on your own and referring yourself. While you may have to pay for the treatment, it may keep your health from being jeopardized.
I WANT TO SEE A PHYSICIAN OUTSIDE OF MY HEALTH PLAN'S NETWORK. WHAT CAN I DO?
Some health plans allow you to see a physician outside of your network if your primary care physician authorizes it. Explain to your primary care physician why you believe it is necessary to see a physician outside the network. Ask your primary care physician for a referral. If the primary care physician refuses, ask why.
Some health plans allow you to go outside the network without a referral but require you to pay a greater share of the cost if you do. Read your health plan to find out whether you may go outside the network and get reimbursed later.
Finally, be prepared to convince the health plan why you believe that there is no doctor in the network who can adequately treat your medical condition. For instance, maybe you have a particularly rare or unusual disease which requires specialty care not available in the network. If so, explain this to the health plan.
MY HEALTH PLAN SAYS A TREATMENT RECOMMENDED BY MY DOCTOR IS "EXPERIMENTAL" AND THE PLAN WON'T PAY FOR IT. WHAT CAN I DO?
Read your health plan. Find out how it defines "experimental" or "investigative" treatment. Then, set up an appointment with the physician who recommended the treatment and show the physician this definition. Ask the physician to write a letter explaining why your treatment does not fall within the contract's definition of experimental care. Submit the physician's letter to the health plan and ask it to reconsider its previous denial. If your health is at stake, consider hiring an attorney to help.
HOW CAN I FIND OUT HOW MY PHYSICIAN IS REIMBURSED BY MY HEALTH PLAN?
Minnesota law says patients have the right to know how payments are structured. Any agreement that prohibits a health care provider from telling you this is void. Minnesota law requires a health plan and a physician to provide you with a description of the reimbursement methods used to pay providers. This must include any method that creates a financial incentive for a provider to limit or restrict the treatment you receive. There are at least three times that you must receive this information: when you join a plan, during open enrollment, and at least annually. In addition, the health plan and physician must give you certain information when you request it. You have the right to know the following: the provider's payment plan; a description of any incentives that involve the transfer of financial risk from the health plan to the physician, and, a description of any compensation plan that is dependent on how much or how little health care is provided.
DO I NEED TO GET A REFERRAL TO AN OB/GYN?
Under Minnesota law a female patient can obtain direct access to an ob/gyn without a referral from a primary care physician, as long as the ob/gyn is within the network.
MY MEDICAL CONDITION REQUIRES ME TO MAKE REPEATED VISITS TO SPECIALISTS. DO I NEED A REFERRAL EACH TIME?
Under Minnesota law health plans must have procedures you can use to apply for a standing referral to a specialist. Check the criteria you must meet in order to obtain a standing referral. Contact your health plan for more information, then enlist your physician's help to request a standing referral from your health plan.
MY EMPLOYER JUST CHANGED HEALTH PLANS AND MY DOCTOR IS NOT INCLUDED IN THE NEW HEALTH PLAN. DO I NEED TO STOP SEEING MY OLD DOCTOR RIGHT AWAY?
State law says health plans must have written procedures which allow you, if you have special needs, risks or circumstances, to continue seeing your doctor for up to four months after becoming covered by a new health plan. This is called "continuity of care." Upon request the health plan must give you a copy of the written procedures for continuity of care.
IN MY HEALTH PLAN SAYS THAT IT WON'T PAY FOR EMERGENCY SERVICES I RECEIVED BECAUSE I COULD HAVE WAITED UNTIL THE NEXT DAY FOR A CLINIC APPOINTMENT INSTEAD OF GOING TO THE EMERGENCY ROOM. WHAT ARE MY RIGHTS?
Minnesota law requires that emergency services be covered whether they were provided by a participating provider or not. These services are also covered if you are within or outside your health plan's service area. When considering coverage for emergency services, the health plan must look at the following:
- a reasonable person's belief that the circumstances required immediate medical care that could not wait until the next working day or next available clinic appointment.
- the time of day and day of week the care was provided.
- the symptoms at the time the patient received the emergency care and not just the after-the-fact diagnosis.
- the patient's efforts to follow the health plan's procedures for obtaining emergency care, together with any circumstances that precluded using these procedures.