EPO Vs HMO and Prior Authorization

Nov 1, 2015

  1. lovethepirk
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    lovethepirk New Member

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    Hi, thanks in advance.

    I'm self-employed and I use the ACA/obamacare to get my health insurance.

    I'm looking at two almost identical plans for 2016 except one is slightly more expensive as it is an EPO and the other is a HMO.

    I rarely go to any doctor and I do not have a primary care doctor which is needed inside an HMO to see a specialist, but the EPO doesn't have this requirement...I like that b/c if I have the sniffles I just bare it out, but if I'm really messed up(ie somethings torn/broken) I just want to swing into a specialist immediately.

    My confusion rests in getting an MRI tho...in an EPO if you know you need an MRI and you must get prior/pre authorization how in the hell do you get the authorization? Can I just call my provider, get a form, and bingo, I get authorized or denied based on what I tell them? Or inside an EPO do I just bypass my primary and get a recommendation from an Orthopedic doctor and then send that to the provider to get the prior authorization?

    Thanks.
     
  2. beachgal
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    beachgal Expert

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    So, it sounds like the HMO Gatekeeper would refer you to a specialist. The specialist will give you a recommendation on the MRI. The carrier must approve the request (give authorization). That is usually done behind the scenes between the provider and the carrier. The provider will receive an authorization number from the carrier. Must have this or you will be stuck with the bill.
    The only difference with the EPO is you can go directly to the specialist without the referral. Still must have the authorization from the carrier.

    In either case, the authorization comes from the carrier to the provider.
    Sometimes people think referrals and authorizations are the same thing. They are not.

    Hope this helps!
     
  3. AllenChicago
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    AllenChicago Guru

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    A somewhat related question..

    What happens if you're at home, or driving around town and need immediate medical care due to chest pains, or something similar. You're on an HMO, and end up at a hospital that is not part of your HMO network.

    Will your insurance cover you with your In-Network deductible/coinsurance limit? If so, have you met your deductible for the year? Anyone know?
     
  4. beachgal
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    beachgal Expert

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    A life threatening event is covered anywhere as if you are IN network.
     
  5. YouGotMyMoney
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    YouGotMyMoney Guru

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    My brother is on FL Blue Options (EPO) got an MRI, and he did need pre-auth.
     
  6. kgmom219
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    kgmom219 What's Next?

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    You need to speak to a licensed insurance agent in your state....
     
  7. MBSC
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    MBSC Expert

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    This is correct. The patient does not submit a form. It is handled behind the scenes between the specialist and EPO.
     
    MBSC, Nov 5, 2015
    #7
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