Referral FAQs

As a member of a health maintenance organization (HMO) plan, you need to understand the basics of how to use your plan so that you know how your health care services are covered.

This includes understanding that:

1. You must select a primary care provider (or PCP) to coordinate your care.
2. If you see a specialist, you must have a referral from your PCP. (If you see a specialist without a referral from your PCP, you may be responsible for the entire bill—not just a copayment or deductible.)
3. If you see a specialist, you may be responsible for paying out-of-pocket for services that have not been approved, arranged, or provided by your PCP.

Please remember that you are responsible for confirming with your Health Plan if the services provided to you will be covered and to ensure that necessary referrals or authorizations are obtained before your visit. Our practice works with your Health Plan to obtain referral authorizations on your behalf, but the ultimate responsibility is yours. You are also responsible for paying for covered services that are subject to your deductible, if you have one, until your deductible is satisfied.

We suggest specialists in the Winchester PHO referral circle so that we can better coordinate your care and advocate for our patients. If there are services that we are not able to offer in Winchester PHO or through our greater Beth Israel Lahey Health partners, we will work with you to make sure you are receiving the proper care.

The Winchester PHO works directly with your PCP and his/her office staff to coordinate your care with the specialists within the WinPHO referral circle.  This is because your Primary Care Team knows your history and health care needs, and can help you decide whether a specialist visit is right for you. Our PCPs refer to specialists whom they know and trust and with whom they have a relationship. This way, toegether, we can coordinate and provide you with the greatest degree of collaboration to help you get high-quality, timely, and effective care.

I’m sorry you feel this way. If you are concerned about a health care decision, it is important to discuss it with me. I’m committed to making sure you get the best care and that there is timely and effective communication among all the doctors you see.

Our relationship is a partnership that is built on trust. We are committed to working with you so you get the care you need to keep you healthy. If you still disagree with our recommendations, let’s work together to find a solution. We hope you understand that our first priority is your health, so every decision is made to provide you with the best care.

There are major differences between a PPO and an HMO. First, a PPO does not require a referral—you can see whatever provider you want. An HMO, on the other hand, requires that a PCP coordinate all your health care needs.

Your PCP care team will work with you to coordinate any services or treatments you receive. In this role, we know and understand your health history and your health care needs—including whether you need to see a specialist.

When you do need to see a specialist, we will refer you to a member of our high-quality provider team within the Winchester PHO referral circle. We will work collaboratively to see that you get the care you need at the right place and at the right time.

You do have second opinion benefits under your HMO plan—and this would be coordinated through our office using the qualified providers within the Winchester PHO referral circle.

Let’s work together to discuss your needs and expectations, and then determine which specialist you should see.

I’m sorry you feel that way. We are committed to working with you to ensure you receive the best care. Working with specialists in the Winchester PHO referral circle will allow us to better coordinate your care and advocate for you.

In addition, this will ensure that you are getting the right service at a lower out-of-pocket cost to you. Your insurance plan will be able to confirm this. Just contact member service on the back of your card.

Let’s talk about your frustrations and see if we can find a solution together.

Generally, we refer to specialists and hospitals within our referral circles with whom we work closely with, because this allows for better coordination of care.

Let’s discuss your concern so we can work together to meet your child’s needs.