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Insurance Plans
General Information
About HMO Insurance

About HMO Insurance
The Health Maintenance Organization (HMO) concept is a cooperative system that seeks a spirit of cost containment from physicians and patients in order to keep insurance premiums down, but still provide for superior preventive medical care.

In the past, there was an era when the courts were filled with many medical lawsuits. The past climate allowed for attorneys to easily link any caregiving physician to a suit. As a result physicians were ordering excessive testing in fear of potential malpractice suits. The insurance companies realized that good and confident physicians could save them revenue and thus pass the savings on to the insured by lowering the premiums. At first insurance companies gave physicians a portion of the savings as a reward for helping to keep the costs down. Today it is now the standard to keep the unnecessary testing down. If a physician "over orders" it now comes directly out of the physicians pocket.

Many physicians are feeling the pressure especially when patients demand unnecessary testing or referred care to outside physicians even though the primary care physician is quite capable.

In order to make this HMO concept work, i.e. help keep your insurance premiums low, we must make you aware of procedures to follow.

  1. Referrals
    HMO patients must get a referral for any medical care or diagnostic testing outside of the primary care office. Referral must be preauthorized. If you forget, then you will need to deal with the insurance company directly as you will be liable for those services not preauthorized. This includes services recommended by another physician such as a consultant, so please do not forget to call first.


  2. Emergencies
    "Life threatening or fear of losing bodily function" are exceptions to this. Fevers, pink eye, simple cuts, injured intact extremities, chronic symptoms, etc. are not so urgent that you can not call first for not only a referral, but for instructions on how to proceed so that there are no further complications.


  3. Independent Physician Association - (IPA)
    As a group, Children & Teens Medical Center belongs to 2 IPA's. Tri-County Physicians Association (TCPA) is in Barrington, and our main referral hospital is Good Shepherd Hospital. Our specialists also mainly practice in our area but sometimes our specialist may not.

    Northwest Primary Care Alliance - (NWPCA)
    is in Hoffman Estates and our main referral hospital is Saint Alexius Hospital.

    Each IPA has its own set of referral physicians. Altough a physician may be on an insurance plan, they might not be a member of the IPA, so you will not be issued a referral. You may go to any physician you like, but without a referral you will be responsible for payment of that physicians services.


  4. Copays
    Copays must be paid at the time of service (by contract). The added cost of billing defeats the HMO concept of trying to keep costs down.


  5. Finally
    As you can see, there are many "rules" to follow with this concept. It is not for everyone. Ultimately your insurance is your choice but we feel it is important that you know these basic things.
HMO insurance may not necessarily get you what you want, but with Children & Teens Medical Center, it will get you what you need.


©Children & Teens Medical Center 2006