PPO is the better than HMO. In fact, I think HMO is unethical for the most part. You will typically hear/read something like it depends on your needs. And that if your PCP is in the HMO network, and you/your family don’t expect to see specialists much, HMO is cheaper (lower copays and deductibles). Even if you require a specialist, the brochure will tell you that HMO just requires a referral from your PCP, and people will probably think that this isn’t a big deal and well worth the attractive price tag that is HMO.
So far so good right? Now here’s what your insurance provider will not tell you, and let me lead with an example. Suppose you over-exerted yourself during your morning workout, and your heart behaved irregularly for a couple seconds which was enough to cut the blood supply to your brain so you pass out. Naturally, you fall down but unluckily fractured a bone in your arm. Once on the ground, your heart jump back to its normal rhythm, blood gets into your brain and you wake up. Your buddy has already called 911, and an ambulance comes, grabs you, and drives you to the ER. HMO covers ER 100% so it’s all good. The ER doc orders ECGs, x-rays, ultrasound… you know – the works, and you are given treatment for you heart and a splint for your arm. The doc tells you to see a cardiologist at your convenience and an orthopedic ASAP to see if you need surgery and also to replace the splint with a proper cast. Unfortunately, this happened Saturday, so you wait till Monday to call your PCP. Monday comes, you call and your PCP’s front desk tells you the doctor won’t be in until Wednesday. You explain the urgency, and all you get is silence on the other end. To add insult to injury, he/she refuses to disclose whether or not the doc is on vacation going as far as suggesting that you should change your PCP if it’s really urgent (true story). Wednesday rolls around and you see your doctor. Your pain has been getting worse each day. The doc barely glances at your ER report before instructing her staff to submit the referral and sending you on your way. Until that referral gets authorized by your HMO provider, you cannot make an appointment with the specialist. Getting treatment without authorization by your insurance will result in you being fully responsible financially which in this case would easily be several thousands of dollars. Over the course of the day, you keep checking your online portal which has nothing under referrals submitted. The fine print states that referrals could take 5-10 business days to get approved… you keep calling your PCP and insurance to no avail. After a few days, you get the approved referral via snail mail, and you get treated. It has been 2 weeks since the incident, and there’s nothing the doctor can do. You’re told you have a few months left and you die.
Kidding – everything turned out OK but you ended up missing a lot of work. Took all the PTOs you were saving up to take you family to Hawaii. You bang your head against the wall thinking why you didn’t just choose PPO in the 1st place and make an appointment with a specialist on ZocDoc. Would’ve actually saved you money, headache and PTOs not to mention all the anxiety.
In summary, just select PPO. In fact, select anything similar to PPO just not HMO. Lessons learned:
- A lot of medical paperwork are (and rightfully so) electronic these days, but the best software engineers do not aspire to work for companies like Aetna, Kaiser and BCBS; let’s not even mention local hospitals/clinics. As a result, medical software integrity is a joke compared to say an Apple or Google product.
- It’ss nearly impossible to get a hold of a live human being from the insurance company. You always get some automated machine. For me personally, I scoured the web to find a number that got me in touch with a real person at BCBS; that number has recently been disconnected.
- It is not just your PCP who’s the gatekeeper when it comes to specialists. It’s also their staff whom are ofter clueless and incompetent, and it’s prayer whether or not the submit your referral properly. On top of that, it’s the insurance company itself who’s the final gatekeeper. And due to the inherent conflict-of-interest (they make less money if they approve your referral) your wellbeing is completely in the hands of the few people working at the insurance company who actually care (in my experience, most couldn’t care less).
- Insurance companies are profit-oriented and really don’t care about your wellbeing. They take there time when it comes to approving a referral (if they do decide to even approve) from your PCP if you have HMO. This is done at your expense because your condition could be getting worse. You will most likely require more expensive treatment which sucks for your health and wipes out any cost savings afforded by electing HMO.