What are Medical Groups and How Are They Different From HMOs?

If you have been on an HMO insurance plan, you may have heard the term medical group. Medical groups are arguably the most important aspect of your HMO insurance, but like most you may be unaware of who they are.


What is a Medical Group?

Health plans contract with local groups of doctors to provide your healthcare. These groups of doctors are called medical groups. While a small number of health plans – fewer than twenty – insure most people in California, there are hundreds of medical groups within the state. This is because the needs and relationships for local patients isn’t something that can be easily stamped out in a cookie cutter fashion. Each county can vary greatly from one another in terms of number of doctors, average medical cost for services, patient education needs, and more. Hence, medical groups are created on the local level to ensure the needs of both the patients and the doctors are provided for.

The difference between a medical group and a health plan sometimes isn’t always clear for the patient. The medical group’s job is to care for patients – this work is done by the doctors, nurses, therapists and other professionals in the medical group. The health plan is responsible for seeing that its members can access care easily by contracting with enough medical groups in a local area so it is convenient for members to get care nearby. The health plan pays for the care as well and typically determines what services and the amount that will be covered. This relationship can be best explained in the picture below.

The job of a health plan and its contracted medical groups can vary depending upon the type of health plan. In a PPO plan, the doctors’ and medical groups’ main responsibility is to care for patients. In an HMO plan, the doctors and medical group often have a bigger job – in addition to providing patient care, the medical group is responsible for the patient’s overall health – including steps to avoid future health problems. The medical group and its doctors’ care and service for HMO members is explained below.

Why Are Medical Groups Important to Me?

There are two main reasons why medical groups are important to you, as an HMO member.

First, it is usually the medical group or one of its doctors, not the HMO health plan, that decides what care you receive and how you receive it. For example, the medical group:

  1. Checks that its doctors are providing the type of care that’s been proven to work.

  2. Sets the rules for you to receive a referral to see specialists and get other care.

  3. Decides the steps doctors must follow when diagnosing and treating health problems.

  4. Validates the training and experience of new doctors.

  5. Schedules when and how long you see your doctor or other staff.

  6. Decides where you go for hospital care and other medical services.

Second, one doctor cannot take care of every medical problem that you may have. The doctors in a medical group work together to make sure that you get all the care you need. These doctors include your primary care doctor and other doctors known as specialists.

Important Note! Because the Medical Group determines who you can see, it’s important that you ensure all your doctors accept the same Medical Group. To find out if they do, you may either call each doctor or work with a broker who will research this for you. If you happen to choose a Medical Group that your doctors don’t accept, then you will not be covered by your Health Plan when you see them. Interestingly, each Medical Group only works with certain Health Plans. Because of these selective partnerships, there are Health Plans with great benefits that may not be available to you because they unfortunately do not contract with your doctor’s Medical Group.

The good news is that you have access to great benefits with reasonable rules. The responsibility is often up to you to ensure you are able to maintain your continuity of care (meaning to continue all current doctors and services). Medicare has rules stating that each broker should ensure this continuity of care doesn’t get interrupted, but many will have stories that say otherwise. For this reason, setting up a Medicare Advantage Plan best fit for your individual needs is of utmost importance, and further, finding someone trustworthy to help you through the decision making process even more so. Once your Health Plan and Medical Group are set up properly, the plan will take care of itself…and you.

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