Point of Service Plans

Some people get confused by all the abbreviations in medicine. They don’t know if they have a PPO, a POS, an HMO or an ASPCA! Let’s take a look at a Point of Service Plans (POS) and see how it works.

POS plans became popular in the 1980s, when healthcare industry leaders were looking for ways to curb costs and still provide quality services. They were, and still are, set up by managed care organizations (MCOs). The MCO is a company that negotiates with healthcare providers, including doctors, hospitals, laboratories, and other healthcare providers.

The MCO basically guarantees the doctor a pool of customers, and in exchange the doctor agrees to serve these patients at a reduced cost. The doctor also benefits from speedier reimbursement for services.

When you join a Point of Service Plan, your first step is to choose a primary care physician—a PCP. Then, no matter what type of health ailment you develop, you must contact your PCP before you can see any other type of doctor. As a provider in the POS network, your PCP has agreed to make himself available for medical decisions at all hours of the day and night, and when he cannot be available then he has designated another physician to cover his patients.

That’s why it’s important, if your employer is changing your health insurance plan to a Point of Service Plan, to determine whether your current family physician is in the network. If so, you can choose him as your PCP and continue to see him for your healthcare needs. If not, you will have to switch doctors. Most POS plans allow various family members to choose different PCPs if they wish.

In the event that you do join a POS plan and you can remain with your primary care physician, it is important to notify him that you are now in a POS plan—or that you have switched from one plan to another. Generally the various plans have different rules, and his office assistant will know them, but you must take responsibility for informing them.

Consumers enrolled in Point of Service Plans cannot seek services from an outside healthcare provider unless the PCP determines that equivalent services are not available within the network. In that case, the plan will pay for out-of-network care. If the PCP cannot convince the plan that you need to go outside the network, you will be responsible for the costs incurred above and beyond the standard in-network POS plan reimbursement.

Even if you want to receive emergency medical care, unless your life is imminently threatened, you cannot go to your local hospital’s emergency department without the authorization of your PCP. This is one way that your Point of Service Plan ensures people are not abusing their insurance and seeing an emergency room doctor for something that could wait until regular office hours.

Point of Service Plans, like other managed care plans, often require providers to participate in utilization review (UR) teams. These teams are made of up healthcare professionals who review each other’s work to ensure that quality care is rendered exactly as described, with services neither more nor less than required to maintain the patient’s health.