U.S. Healthcare 101 / Remedial edition

January 7, 2017 5:33 AM

Despite being a lifelong American, I still don't really understand our healthcare system. Can you give me some info - treat me like I'm 5 years old.

I'm a 40 year old female. Went to a pediatrician regularly as a kid. Then saw a Gynecologist in college as part of our college's healthcare system. After graduation, I went to Planned Parenthood for annual exams, to continue on birth control, until I had insurance. At that time, I started seeing another Gynecologist every year or so for annual exams. That's the extent of my doctor visits, essentially.

I'm now at the point where I need to see a specialist for a lifelong health condition (which hasn't needed much attention until now).

How do I figure out who to see, and how do referrals work?

Insurance deems that I need a 'medical home'. So I chose a clinic near my house. According to their website, they have Internal Medicine docs and Familiy Medicine docs and Nurse Practitioners. Do I just call them and say I want a general checkup? Which type of doc do I want? Do I just have them pick one, and then if I don't like them after the first visit, I choose a different one?

What do we do at this checkup? Bloodwork, where results aren't immediate? Do I just say I need a referral and that's pretty much it? Can I see an IM or FM doc for my annual gynocological exam, or is that only done by OBGYNs?

How do referrals work? I know the specialty I need to see (neurology), but I need to figure out which neurologists in town have experience with my rare condition. Do I just start calling neurology practices and asking which docs in their practice know my condition? (their websites don't always list subspecialties).

When I ask for that referral, do I need to tell the general doc the name of the specialist I want to see? Do they have to make the appointment for me? Can they help me choose a neurologist?

If the neurologist is booked out a ways for appointments, can I set the appointment myself before I have the referral, just to get in the waiting line? As in, I set an appointment for neurologist for June, but see general doc in April to get the referral.

Thanks for any insight you have!

posted by anonymous to Health & Fitness (14 answers total)

Do you have a PPO or HMO plan or some other kind of plan? It makes a difference, as for example, with a PPO you would not need to get a referral from your Primary Care Provider (PCP) to see a specialist, but with a HMO you would. Did your insurance specifically mention the need for a PCP?
posted by peacheater at 6:16 AM on January 7, 2017

It actually even depends on the HMO. There are HMOs where you can self-refer to a specialist, as long as that specialist is in-network. If I've got a weird skin thing, I don't have to see my primary care doc first, I just call the dermatologist directly.
posted by soren_lorensen at 6:44 AM on January 7, 2017

(Just interjecting to say I'm totally following this, and I think the difficulty and complexity of the US healthcare system is treated like a feature rather than a bug -- the more complex and awful something is to navigate, the less the number of people who will actually navigate it successfully to claim their entitlements. Don't feel dumb for being confused or overwhelmed. It IS confusing and overwhelming.)
posted by schadenfrau at 6:55 AM on January 7, 2017 [8 favorites]

Your insurance has a phone number. Many of these questions you need to ask them directly. The answers depend on the details of your plan. Your doctor's office and a potential specialist's office can also answer your questions.
posted by andoatnp at 7:00 AM on January 7, 2017 [5 favorites]

A lot of American insurance companies want you to have a primary care physician, i.e. a PCP, who you go see first and who then refers you to specialists. That person can either be a a General Practioner, a family medicine doctor, or an internist.

So I would call up the clinic and tell them that you're looking for a primary care physician. If the clinic has a website, you can look up the doctors in advance and see if you like the looks of one and ask for that person in particular. If you have no idea, then just ask the receptionist if any of their family medicine doctors or internists are taking on new patients, and if so, ask if you can schedule an appointment with one of them. If the receptionist asks the reason for your appointment (they don't always), tell them you need help with a referral.

Then you go to your appointment and tell the doctor about your situation. They may do some tests like bloodwork so they can assess your condition themselves. Then they'll give you a referral to a specialist, who, in my experience, will re-do all of the tests themselves that your primary care physician already did, because doctors like to do that.

You can call a specialist out of the blue and ask for an appointment, but a lot of the times, their systems aren't really set up for that--particularly if you're a brand-new patient--so it can be a bit of a hassle. Also, many insurance companies won't cover visits to specialists if you don't first have a referral from a primary care physician. If you find a PCP you really like and trust though it's easier, because then (at least in my experience) you can trust the specialists they refer you to.
posted by colfax at 7:11 AM on January 7, 2017 [2 favorites]

If you don't like your doctor you can ask the front desk person how you go about switching to a different doctor. At some offices they want to know why, at some offices you have to get the first doctor to sign off on the transfer and a second doctor to accept you as a patient. They won't always accept you.
Please double check with your insurance that the clinic you are looking at will qualify as a medical home. Most often by medical home they mean an accountable care organization, not just a primary care physician- although sometimes people use these terms interchangeably.
Some internists will have their NPs do gyn care, some will want you to have a seperate gyn person.
Yes you can call the neurologists office and ask if they have experience with X condition but be prepared for vague responses: I've had more success asking " what experience have you had with X?" How many patients a year? Your internist might be able to guide you towards the most experienced neurologist.
The thing about American healthcare is that it is all on you to know, to understand, to do the research, to ask the questions. It's exhausting so just know you are in good company.
posted by SyraCarol at 7:31 AM on January 7, 2017

Even if the neurologist is booking pretty far out when a patient calls, they typically have slots open for more emergent appointments and faster referral appointments if your doctor's office calls. I don't have to get a referral to see a specialist but I almost always do just because my GP's office has an awesome scheduling department who can always get me in way faster than I can manage for myself, and is able to get access to specialists who are closed to new self-referred patients but will take doctor referrals. Depends on the GP you choose but it may be an option!

In my experience asking on Facebook from your local friends ... "I need to find a good GP who's taking new patients, I have X insurance" will result in a dozen people telling you they have the same insurance and their awesome GP is Dr. So-and-So.

I've also had good luck telling the scheduling nurse, "I need to choose a primary care provider, and my biggest health issue is $condition ... is one of your doctors particularly good with patients who have neurological concerns?" Sometimes they're just like "eh" but sometimes they can tell you which of their doctors is particularly good with whatever.
posted by Eyebrows McGee at 7:46 AM on January 7, 2017

Regardless of insurance regulations, my experience with neurologists is that they will not take a new patient unless they're referred by another physician.I suppose this is so people with headaches treatable by other means don't waste the neurologist's time.

Anyway, here's how it worked for me. I went to my insurance's website, looked for in-network internal medicine docs nearby, picked one sort of blindly, and went to him. He's not the most friendly guy in the world but I don't have to see him that much so I'm too lazy to switch. I would ask your friends if they recommend a particular person. A Facebook post is probably the easiest way.

At a physical, he'll order some labs (bloodwork). Sometimes they can be drawn in the doctor's office, sometimes they'll send you to another location. Try to make sure the lab is in-network! I got dinged for $200 once because I didn't know. For regular stuff he can send the order to any lab, like he can send a prescription to any pharmacy. So you can pick one from your insurance website again. Drawing blood is drawing blood; they're really all the same in my experience so pick one near work or home.

My doctor's practice has a website where I can log in and see the results of my labs. A nurse usually calls me to discuss them. If there's anything really off, the doctor will call and/or make a follow-up appointment.

If I need a referral, my doc has someone in his office whose job is to help set up appointments. They ask me what general location is convenient for me (e.g. "west side of town") and what times/days. Then they call while I'm sitting there. Again, I try to make sure the doctor is in-network first.

You can certainly try to make an appointment with a neurologist first but if you don't have a primary care doc then you'll probably be turned down.

CONFIRM WITH EVERY DOCTOR THAT THEY TAKE YOUR INSURANCE AND THEY ARE IN-NETWORK. DO THIS EVERY TIME. Insurance websites can be outdated. If they take your insurance on December 31, they may not take it on January 1 and you will get a big unexpected bill. If you call your insurance and anything they tell you on the phone sounds hinky or not in your favor, get it in writing. I literally made someone wait on the phone until I received an email from them. They are not your friends.

Medical billing staff are also not your friends and have the IQ of goats. Double-check every bill you get to make sure it's for a service you actually received. I realize this was not in your original question but since you (no offense) are ignorant about some basic things, I don't want you to get taken advantage of by their malice or incompetence.
posted by AFABulous at 7:54 AM on January 7, 2017 [3 favorites]

You may need to start with a list of "in network providers." You will need to call to see if the general practitioner or clinic you want is even taking new patients. This is currently a problem in at least some parts of the U.S.

Your annual gynocology exam needs to be done by a gynecologist. But you might also want a general physical from a general practitioner.

Although not specifically required, doing your own research by calling around can help you advocate for yourself and get better care. Doctors themselves can be kind of overwhelmed by the complexity of the system.

So calling around, asking questions and making a list of neurologists that address your issue can be helpful. You may need to think about how to present that information in a way that your doctor finds palatable. It probably won't go over well if you come across like you know everything and you are just paying them to be a glorified lacky who signs off on all your decisions.

When I had a serious issue, it worked well to go in and say "This is my situation. I want this list of medication -- and anything else you can think of." It acknowledged their expertise and let them have a say while also communicating that I already knew a lot about my medical condition and what worked well for me. So, it is fine to go in with some preconcieved ideas about what you want, but don't communicate it like the doctor's role is just to check this box so you get what you already decided you want (unless you are my mother -- she somehow can pull that off at times).

You might also find it useful to request a formulary from your insurance. This is the list of drugs they cover.

I would just let them know that this is the first time I have needed serious medical intervention, so I am not sure how things work. Then ask whatever questions you have.
posted by Michele in California at 9:43 AM on January 7, 2017

I have always gotten gyn exams by my primary care doc. If all you need is an exam and Pap, it's easy to do it one stop as part of the free annual physical, unless you have more complicated issues that definitely require a gynecologist.

At that appointment is also a great time to say "I need to see a neurologist for X problem--do you have someone you recommend?" They may or may not, or they may have someone they can ask about your specific condition and get back to you with a referral later.

In any case, if it's a non-emergency, you can expect to wait awhile before you see a specialist (3 months for a rheumatologist, and I think neurologists are similarly limited in number), so you can make the appointment first and then contact your primary care doc's office for a referral.
posted by hydropsyche at 9:44 AM on January 7, 2017 [1 favorite]

Even if your insurance doesn't require you to get referrals from a primary doc, it's nice to have one managing your care. I also get my gynecological exam from my primary.
posted by radioamy at 9:47 AM on January 7, 2017 [1 favorite]

Oh, also, there is a major benefit to having your primary refer you to a specialist--it makes the specialist more accountable. A lot of them rely on primary referrals for their business, and they want you to go back to the primary and tell them how great they were. If a specialist is a jerk or a bad doctor or whatever, they're going to stop getting referrals because patients are going to complain to the primary.
posted by radioamy at 9:49 AM on January 7, 2017 [1 favorite]

It really depends on your type of insurance. Do you have a PPO (where you probably received a list or book of in-network providers) or an HMO (like Kaiser). With a PPO, you can call up and make an appointment with anybody in the book/network and with those doctors, you'll get discounted rates. With an HMO, you must begin with your Primary Care Physician -- if s/he thinks you need a specialist, s/he will refer you to their choice (who will also be a member of the HMO). In my experience they then set up your new appointment.

Of course, you can call up any doctor and make an appointment. (The 'gotcha' in these times is, that doctor may not be / is probably not accepting new patients.) If you have a PPO, insurance may pay some of the cost, even if the doctor is outside the network (ie not in the book). If you're in an HMO, if the doctor isn't part of the HMO, you'll be paying the full cost.
posted by Rash at 10:01 AM on January 7, 2017

Depending on how active you want to be with this selection, I'd look for a neurologist who is in-network for you and has experience with your condition. You might be able to find such a doc through your insurance provider's website.

Then, if possible, try to find a primary care physician who is in the same hospital/clinic network as a neurologist that you like (or, if you aren't wanting to be that picky about your specialist, just choose a clinic network that has a decent number of neurologists in it.

Being in the same clinic system makes referrals, records transfer, billing and insurance stuff so much easier. In theory, in this electronic medical record age, your records should follow you wherever. In practice, it's just easier to coordinate with doctors who are all accessing the same computers.
posted by sparklemotion at 11:03 AM on January 7, 2017