FREQUENTLY ASKED QUESTION

 “FAQ”

 

1.               What is a Primary Care Physician?

 

Primary Care Physician, also referred to as the PCP or Primary, is the current term referring to your internist, family physician or general practitioner who is trained to care for most of your medical problems.  As nicely stated by one of our primary physicians, “The PCP is the captain of your healthcare ship”.   Most health problems are best initially evaluated by your Primary Care Physician (PCP).  He or She is your best source for the initial care of any ailment, and for ongoing care.  As an example, uncomplicated hypertension, or uncomplicated diabetes, are generally best handled by your PCP who will treat you with all of your other health care problems in mind.  For complicated problems, or unusual diagnoses, your PCP is best qualified to determine which test, and then, which Specialist in needed. 

 

2.     I was assigned a Primary Care Physician when I enrolled.   I would prefer another Primary Care Physician who is on your list.  May I change, and what is the process?

 

Of course you may change Primary Care Physicians.   You may switch to another PCP at your discretion, assuming the Primary Care Physician you choose is accepting new patients.  This must be done through your health plan, however the EPMG customer service representative will be glad to assist you in this process.  You may also review our list of physicians at the EPMG web site, www.empirephysicians.com

 

3.       I love my doctor but he is really busy.  I don’t want to bother him for minor things, so what should I do if I have as an example a bad cold or stubbed my toe and it really hurts?

 

Go ahead and call your Primary Care Physician.   If he or she is really busy and cannot see you in a timely manner, you may be directed to a contracted urgent care center.

 


4.     How do I get into the specialist’s office?

 

Most Specialists will contact you directly once they receive the referral (or authorization if one is necessary).  You should not expect that to occur immediately after leaving the Primary Care Physician’s office.  In general, if you do not hear from the Specialist’s office within five working days, it is then OK to call and ask if they have received the referral.  If the answer is “yes”, they will make the appointment with you then.  If “no”, and you believe the matter is of some urgency, you should contact your Primary Care Physician to find out the status of the referral.  If you cannot get a response, the customer services desk at EPMG can and will rapidly assist you.

 

5.       Why does specialty care require an authorization?

 

In many cases, EPMG Primary Care Physician, as well as many of our specialists, can refer you directly to a specialist and no authorization is required.  In some cases a prior authorization is required and your Physician will submit these requests to EPMG, with your health care records, and a determination is made usually within 1-2 days.

 

6.      Why does my specialist keep sending me recall notices?  And why are those visits denied?

 

Many physicians send “recall notices” (come back for an office visit) so that they may check on their patients to be sure they are continuing to do well, provide ongoing prescriptions, and basically to keep in touch.  In coordinated  care, your PCP is providing your ongoing care, often based on previous recommendations of the specialist.  Your Primary Care Physician will refer you for follow-up when there is a significant change in your condition, or if newer treatments become available that requires treatment only by a Specialist.

 

 

7.     My referral has not been approved,  and was told that the request was not a covered benefit.  What do I do?

 

Contact your Primary Care Physician and ask what alternatives might be covered.  If you believe that the denied request is a benefit covered by your insurance, then contact EPMG customer services, and we will research this on your behalf.  You may also contact your health plan if your have questions on your benefits.

 

8.     My referral has not been approved, and I do not agree with the alternative suggestion. What do I do now?

 

First, contact your Primary Care Physician and discuss the recommended alternative. If you still believe the denial was inappropriate, then send a letter to the EPMG customer services  explaining why you believe the referral should be approved.  The case will be reevaluated by EPMG’s medical directors, and by an entire committee of physicians, on your behalf.

 

9.       I have a head cold that is not getting any better, it is two o’clock in the morning and I cannot sleep.   Should I go to the emergency room?

 

This example is used since most patients would not consider going to the emergency room in this situation. The ER is a busy place and is meant for treatment of true emergencies.  True emergencies are “the threat, or perception of a threat, to loss of life or limb”.  Remember that most insurance companies do not pay for an emergency room visit that is not considered prudent, and your co-payment or out-of-pocket cost is normally three times more at the Emergency Room.

 

The appropriate action to take in the absence of a true emergency is to contact your Primary Care Physician or his/her “on call physician” if it is after hours.  You may be asked to come to the office, directed to an EPMG contracted urgent care facility, or directed to the emergency room.  If you follow these guidelines, you are likely to get medical care sooner and you won’t be waiting for long hours in the emergency room.

 

10.     How do I arrange for my annual mammogram?

 

Your Primary Care Physician will refer you at the time of your annual physical exam.  Or, you can call your Primary Care Physician’s office or EPMG customer services and ask for a listing of contracted radiology providers.  You may schedule an appointment yourself, with a contracted facility.

 

11.     I have concerns about my diagnosis or treatment plan.  What do I do?

 

Tell your Primary Care Physician of your concerns.  He or she may request another opinion and EPMG will arrange that for you.

 

12.     What is a Hospitalist and how is he or she involved in my care?

 

Many hospitals and medical groups’ today contract with physicians who specialize in the medical care of the hospitalized patient.  Often, these physicians have additional training in the care of the patient in the intensive care setting.  EPMG works with several highly trained hospitalists who either become your admitting physician, or assist your admitting physician when you require hospitalization.

 

 

13.    My mom is being discharged from the hospital today.  We really liked the Hospitalist doctor.  Can we follow up with him?

 

Unfortunately, the Hospitalist doctor only sees patients in the hospital, except for those referred to him within his specialty.  He does immediately fax a summary of your care, to your Primary Care Physician along with recommendations for follow up care.  The formal hospital discharge summary will also be sent to your Primary Care Physician and any other EPMG specialist who needs to see you in follow up.  You can rest assured that your regular doctor will know what has occurred while you were in the hospital.

 

14.   What is EPMG?  I thought I was insured with an HMO?

 

There is no short answer.  The initials E.P.M.G. stand for “Empire Physicians Medical Group”.  EPMG is an IPA or “Independent Physicians Association”.

As such we are essentially an intermediary between your HMO insurer and your Physicians.   All of the EPMG physicians are part of one group – EPMG, and EPMG is contracted with your health plan to coordinate and provide your health care needs on a local geographic basis.

 

Your insurance is with your HMO insurer.  EPMG administers the insurance contract, and the EPMG physicians provide your medical care.

 

 

15.   The doctor I want to see is an EPMG physician.  How do I get into EPMG?

 

When you sign up with your insurer, you simply ask the agent or representative to list EPMG as your “medical group”.  In some cases, the insurance card does not state the name of the medical group.  When you make an appointment with the doctor, you would say, “I am insured with such and such insurance company with EPMG”.

 

16.     How does EPMG review and approve its physicians and other providers?

 

Most EPMG physician members are well known to their peers, and indeed are often invited to join because of their reputations for providing quality care.  Of course, medical license and other credentials are carefully checked.  The providers credentials are then reviewed by the EPMG Credentials Committee (a group of physicians), and finally its Board of Directors, comprised of local Physicians. All physician credentials are certified by “Credential Solutions” which is accredited by the National Committee for Quality Assurance (NCQA).

 

 

17.     I have questions not listed here.

 

If you cannot find the answers elsewhere on this website, please call EPMG at 770-8678 prompt 2.