by Pam Davis, RN, CBM, MBA
A good healthcare provider is hard to find. I know. I loved my primary care physician. She was with me through all of the ups and downs with my weight, when I decided to have bariatric surgery and afterwards when I needed more support. Then one day, she broke my heart. She sat me down and told me she was closing her practice to work at a walk-in clinic. While I felt like I was losing a friend as well as my physician, I had to be happy for her as this change would allow her to spend more time with her children.
So, I began my search for another primary care physician. I didn’t want just any old healthcare provider. I wanted someone who would:
As fate would have it, I found another primary care physician who met my criteria. He was super nice and no matter how busy his office was, he always made me feel like I was his only patient. When he was in the room, he was fully in the room—listening more than speaking and working with me. Then, my husband and I moved more than 800 miles away and I had to begin the search again.
I know I’m not alone in this search. Life happens after surgery. Let’s face it, life happens before surgery too! We find a physician or nurse practitioner we love (or maybe one we don’t like at all) and our insurance changes. Or maybe we move or they move and now we’re left searching for our next physician or nurse practitioner.
Step 1: Understand Your Insurance Policy
Let’s assume you have healthcare insurance and begin there. You need to know what type of insurance plan you have as well as the specifics of your policy. You may have to choose an in-network provider. The terms used by insurance companies can be confusing. Here is a list of terms to help you better understand your policy:
Health Maintenance Organizations (HMOs): Health Maintenance Organizations represent “pre-paid” or “capitated” insurance plans. HMOs have individuals (or their employers) pay a fixed monthly fee for services, instead of charging for each visit or service. The monthly fees stay the same if you have several visits each month or none. Services are provided by physicians who have an agreement with the HMO. Each HMO is different. Some HMO plans have you visit a main office for all health services, but others have you visit the physician’s own office.
In-network: These are providers or healthcare facilities that are part of a health plan’s network. They have an agreement with your insurance company and offer care at a negotiated rate. Seeing an in-network provider is usually cheaper than seeing a provider who is out-of-network.
Managed Care Plan: A term that covers any form of insurance plan that has requirements. Managed-care plans can be an HMO, Point of Service or Preferred Provider Organization (PPO). Requirements can be pre-authorization or second opinions. The requirements allow your primary care physician to manage all parts of your medical care.
Network: A group of physicians, hospitals and other healthcare providers that have an agreement with an insurance company to provide services at fixed rates. Networks can cover a large geographic area or a wide range of healthcare services. Insured individuals typically pay less for using a network provider.
Out-of-Plan (Out-of-Network): Physicians, hospitals or other healthcare providers who are not part of your insurance plan (usually an HMO or PPO). Not all plans allow you to see providers out-of-network. If you do not have coverage of out-of-network visits, you will pay 100% of the costs involved. Some plans allow for out-of-network visits, but charge a higher rate or have you pay a percentage of the cost of the visit.
Preferred Provider Organizations (PPOs): Insurance coverage that uses a pre-selected group of healthcare providers. You will pay less for visiting these providers. If you use a physician outside the PPO plan, you will pay more for medical care.
Primary Care Provider (PCP): A healthcare professional (usually a physician) who is responsible for taking care of someone’s overall healthcare needs. Typically, a PCP serves as a “quarterback” for an individual’s medical care. They see patients for all concerns and give referrals for specialist care.
Provider: A healthcare professional who gives healthcare services. The term can refer to physicians, but it also includes other healthcare professionals such as hospitals, nurse practitioners, physical therapists and others offering specialized healthcare services.
Additional information regarding insurance plans and coverage of bariatric surgery can be found on the OAC website under the Access to Care Resources section.
Step 2: Research Your Options
Now that you know how your policy works, visit your insurance company’s website. There you can search for providers in your area. Once you find the providers closest to your home or work, look at their reviews. Common sites with trustworthy reviews include Healthgrades, Google and Yelp. I know, it seems odd to look at physician reviews on Yelp. However, this is the way of the world we live in. The best and most trustworthy resources of information on this are your friends and family, followed by online reviews.
Step 3: Find Out if They Specialize in Obesity Medicine
How do you know if a PCP or nurse practitioner near you understands obesity and metabolic health? You have your list of who is covered by your insurance plan and you’ve checked their reviews. Now check to see if they are listed on the OAC Obesity Care Providers (OCP) website available at ObesityCareProviders.com.
You can also begin your search at this site. It allows you to search by zip code and specialty. After you find healthcare providers that specialize in obesity medicine in your area, you can check to see which providers are covered on your insurance plan.
Congratulations! You Did it!
You found a provider that’s covered by your insurance, has great reviews and is listed on the OCP website. You have an appointment for next week. All you need to do is show up, right? Not quite.
To make the most of your appointment and to build a solid foundation with your new healthcare provider, make sure you have a copy of your medical records for the past three to five years. These need to include records of any surgeries you’ve had, your most recent lab results and a complete list of any medications (prescription, over-the-counter, vitamins and supplements) you take on a regular basis. It is also good to include a list of any specialists you see.
Now, you’re ready! One important thing to remember is that if you and your new healthcare provider don’t click, repeat this search and find another. Your healthcare is a team effort and you’re the key player!
About the Author:
Pam Davis, RN, CBN, MBA, is a Certified Bariatric Nurse and a bariatric surgery patient. Pam has 15 years of experience working with individuals affected by obesity. Pam has authored articles, patient education materials, and practice guidelines for treating individuals affected by obesity. In 2015, she received the Integrated Health Circle of Excellence award from the American Society for Metabolic and Bariatric Surgery.
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