HMO
Information
Presently Participating in:Blue
Cross/Blue Shield, Keystone Central, Community Choice, AETNA, EPHIN, Valley
Preferred, Spectrum, Choice Plus, Corporate Health Administrators, Health
One, Preferred Care, US Healthcare
Telephone, Prescriptions, Referrals
and Physicals
When phoning the office or the
doctor, please identify yourself as a member of an HMO. This facilitates
patient identification and allows us to expedite delivery of appropriate
and necessary care. If emergency room care is required, certain HMO plans
allow usage of only certain hospital.
No prescriptions will be written
for over the counter medications, since such prescriptions are forbidden
under your plan. When possible, we write prescriptions for generic medications
as required by your plan.
No visits to other doctor's offices,
associated services or emergency rooms will be authorized "after the
fact". There are no exceptions! This is in accordance with HMO rules
and regulations. We can always respond to emergencies in a few minutes,
and will be happy to determine the appropriate steps for you to follow
at that time. If you prefer to visit a specialist or the emergency room
without our authorization, you will be expected to pay for those services
yourself. Neither your plan nor this office will reimburse you for those
expenses.
When you need to take your child
to a specialist, you will need to pick up a referral prior to your appointment.
We need a minimum of 48 hours to prepare a referral. In a medical emergency,
we will prepare a referral the same day.
Occasionally a specialist may wish
to perform a test on your child. For example, if you are seeing an ear-nose
and throat specialist, and you have a referral for a consultation only,
he may not do a hearing test on your child unless that has been authorized
prior to the visit. This is because HMO says we can do hearing tests at
Children's HealthCare, and therefore can not give a referral for a service
which can be provided for at our office. If you want the specialist to
do a test, eg. a hearing test, without prior authorization, you are free
to pay the specialist yourself.
Occasionally we are asked to give
a referral to a specialist out of the service area. We are allowed by HMO
to give a referral if medically indicated to a specialist who is participating
with your HMO. If you request a referral to a physician who is not participating,
we can not give you the requested referral. We can ask HMO for a non-participating
referral, which they may agree to if there is no physician in their network
who can perform the required service.
Your plan covers physical examinations
at certain times during a child's school career. Sports and camp physicals
are not covered by your insurance even if they are required by the school
or camp. We will be happy to provide these exams at our normal rates.
What you need to know about
HMO
Q. What is managed care?
A. Managed care is a catch-all
term. It describes various health plans organized around networks of physicians
and hospitals that provide care to groups at prices that are lower than
standard private health insurance. Because premiums are less, it's important
to keep the costs of the health care delivered by these plans as low as
possible. To keep costs down, the care has to be managed.
Q. Who manages?
A. The primary care doctor (typically
a pediatrician or family physician) is the "point person" who
manages managed care. Patients in need of preventive care or treatment
of an illness contact this physician. It is this doctor's responsiblity
to make sure that patients are seen as necessary, and treated appropriately.
If there's need for aditional medical care, such as a consultation or treatment
by a specialist or subspecialist, then the primary physician will authorize
it.
Often an HMO will list several
specialists, which the primary care physician may refer to if medically
indicated. Once this is decided, the patient will be given a written authorization
form to take to the consulting specialist. The referral form is typically
good for one visit within a specified time period.
Once the consultant has seen your
child, he or she will send a report back to the primary physician, indicating
the nature of the problem and the proposed treatment. Most of the time
the primary physician will accept the recommendations and authorize them.
It is important that you not make
appointments to see specialists or consultants without authorization, since
we can not give retroactive authorizations.
Q. What if I want a specialist
who is not a participant in my HMO?
A. Usually it's possible to find
a physician within the plan who has the same abilities, background and
other attributes as the preferred physician. Rarely, the specialist needed
is so unique that no substitute can be found. Occasionally, you may need
to travel outside the Lehigh Valley for a participating specialist.
Q. Why can't I take my child
to the emergency room when I feel it's necessary?
A. One of the most expensive patient/physician
interactions occurs when a random patient encounters a random physician.
Since neither knows anything about the other, an elaborative study must
be undertaken to arrive at the cause of a patient's problem.
Too often this meeting occurs in
the chaos of an emergency room where all sorts of trauma and pain are being
treated. It is scarcely the setting for a carefully thought out question
and answer period about the patient's illness. To compensate for this lack
of clinical information, it's often the pattern of the busy physician there
to order tests and x-rays that may take some time.
Contrast this with the office where
the physician knows your child and has the child's medical records. With
appropriate questioning and examination, tests often are not needed and
the patient can be sent home in a short time with appropriate information,
and treatment and, if needed, prescriptions.
Q. What about weekends?
A. A physician is in the office
on Saturday, Sunday mornings and holiday mornings till noon, for sick children,
urgent problems, and emergencies. According to HMO guidelines, there is
an additional charge for visits on the weekends and "off hours".
Q. Are regular check-ups allowed?
A. The frequency of check-ups depends
on the patient's age and condition and on your health plan.
Q. Why are there copayments
at the time of visit?
A. In a perfect society, no one
would ever seek care who did not need it. Unfortunately, there are individuals
who go in pursuit of medical assistance for problems that are insignificant
or unlikely to cause serious difficulty. The copayment or "copay"
is a simple deterrant to overuse of the health-care system. That's why
an off hour copayment may be set much higher than a regular office copayment.
Q. When should I call Children's
HealthCare?
A. You should call whenever you
feel there is a significant problem that either requires being seen or
about which you feel uneasy. If you feel your child has a true emergency,
and you can not reach us by phone within a reasonable period of time, the
emergency room might be the place to go. Generally, however, if you explain
to the answering service or to the office, that there is a true emergency,
we will return your call promptly, and a trip to the emergency room may
be avoided.
When there is a less severe problem,
call our office and leave a message clearly but briefly defining the problem,
and indicating the best time our staff may reach you.
Like everyone else, physician do
not enjoy calling and talking to answering machines! Often it is best to
make an appointment for the same day if the problem is urgent, or later
if it is not. Be sure to phone our office to cancel if you can not make
your appointment- it can save a lot of inconvenience to others, and you
will avoid an additional charge for a "missed appointment".
Children's
HealthCare
1517 Pond Road
Allentown, PA 18104-2253
610- 395-4444